suicide in america “suicide is a national public health problem.” david satcher, m.d. surgeon...

Suicide in America

“Suicide is a national public health problem.” David Satcher, M.D. Surgeon

General of the United States

QPRT Agenda

IntroductionsScope of the problem Introduction to risk/protective factorsMental illness and suicideSuicide Risk Rating ExerciseLunchAvoiding suicide malpractice Introduction/use of the QPRT protocolRole plays and practiceManaging risk over time

Training goals

Describe the scope of the problemAddress social policy/impact on practiceRelationship of mental illness and substance abuse to suicideCurrent status of suicide risk assessmentDescribe limitations of the clinical interview and how to improve suicide risk assessment and management decisions

General approach for today…

Address clinical core competencies to reduce medical errors and help ensure patient safetyEmphasis is knowledge gain and skill acquisition verses interesting statisticsTeach a tested suicide risk assessment documentation protocol Address strategies for suicide risk reduction in clinical practice

From the Surgeon General

“Suicide is our most preventable form of death.”

Why now?

National movement has begun…

National Strategy for Suicide Prevention

Institute of Medicine report (Reducing Suicide: A National Imperative)

Public health is marketing “suicide is preventable”

Public expectations that suicide is a preventable form of death are rising

Why us?

Clinical providers and their employers are charged with doing a better job (Goal 6).Families are being taught suicide is preventable, so “Why did my brother die after I brought him to your hospital, mental health center or substance abuse treatment program?”Lawsuits against us are on the rise (?)

Goal 6 from the National Strategy: “Implement training for recognition of at-risk behavior and delivery of effective treatment”

1. Who is qualified to conduct a suicide risk assessment?

2. What are these qualifications?

3. When is the risk assessment done? How often?

4. Where are staff trained in recognition of at-risk behavior?

5. How is this risk assessment documented?

JCAHO and Suicide

2007 National Patient Safety Goals # 15The organization identifies patients at risk for suicide.

(M) C 1: The risk assessment includes identification of specific factors and features that may increase or decrease risk for suicide.

(M) C 2. The patient’s immediate safety needs and most appropriate setting for treatment are addressed.

(M) C 3. The organization provides information such as a crisis hotline to individuals and their family members for crisis situations.

How big is the problem?Global Violence-Related Deaths1 million people die by suicide10-20 million attemptLeading cause of death in 1/3 of all countries54% of all violence-related deathsGlobal rates are climbing, esp. men

More die by suicide each year than from all armed conflicts around the world

Source: World Health Organization 2009 – www.who.org

Scope of the problem USARange: ideations, attempts, deaths 36,909 completed suicides in US (2009)Attempts: 922,725Estimated 25 attempts to one completionRates vary widely by race, gender, geography, ethnicity, but all deaths have commonalities

Source: AAS – www.suicidology.org

Big picture adult numbers

Think, plan, attempt, die10 million adults think about suicide each year 1.2 million plan a method (gun, MVA, etc)750,000 attempt (minimum count).Approximately 30,000 dieSuicide is 11th cause of death overall- 3rd for young people (rate has almost tripled since 1950s – unexpected upturn 2003-2004.- first for young people in some statessource: National Co morbidity study, CDC and NIMH

American Numbers(averaged over past 10 years)

35,000 + die each yearRate: 11-12 per 100,000/Year90+ per day (1 commercial jet every other day)One person every 15-20 minutesOf the 35,000+ deaths- 4 X male completions to female- 3 X females to male attempts

Suicide is no respecter of age, race, religion, social or economic status; its an equal opportunity mode of death.

States with highest rates for past decade (not ordered)

The following states have completed suicide rates above 15/100,000

Nevada - New Mexico – Montana – Wyoming – Colorado – Alaska – Idaho

What do these states have in common?

Source: AAS www.suicidology.org – these ranks change frequently

http://www.suicidology.org/

States with the lowest rates for the past decade

The following states (and DC) have completed suicide rates below 9/100,000

Rhode Island - California - Connecticut - District of Columbia - New Jersey – Massachusetts - New York

What do these states have in common?

Would access to care save lives?

• Over 90% of all people who die by suicide are suffering from a major psychiatric illness or substance abuse disorder, or both.

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

• Effective, accessible, competent care could save thousands of lives.

Intention and Suicide

“There are ways of killing yourself without killing yourself.”

Tony Manero, Saturday Night Fever, on the “suicide” of his friend.

ILTB = Intentional life threatening behavior

Need for surveillance data

We really do not know the full scope of suicidal behaviors, self-inflicted injuries, risk-taking activities that lead to premature morbidity and mortality.New! National Violent Death Surveillance System is now in place in 17 states and is collecting critical data on 50,000 violent deaths per year, including suicide.

We do know where those identified end up…. In our care and we must do the best we can to keep them safe.

Suicide Attempt

“Any potentially self-injurious action, with a nonfatal outcome, for which there is evidence, either explicit or implicit, that the individual intended to kill himself or herself.”

From Carol, Berman, Maris, et. Al., Journal of Suicide and Life-Threatening Behavior, 1996

Lethality of Suicide Attempts

Suicide attempts vary in lethality. Death can be an impossible result of

some action, or almost a certainty.

Smith et. al., The Menninger Foundation, scales from 1 to 10 (good inter rater reliability). Examples:

0.0 Death is an impossible result of “suicidal behavior,” e.g., light scratches to the skin Wounds that do not require suturing. Swallowing paper clips, coins, 10 or fewer aspirins or clearly ineffective acts which are shown to others.

Lethality of Attempt Scale3.5 Death is improbable so long as first aid is administered by victim or other agent. No effort to hide attempt. Rescue is likely.5.0 Death is a 50-50 probability directly or indirectly. Severe cutting with sizable blood loss. Hanging efforts with chance of discovery high. Vague drug overdose.7.0 Death is the probable outcome unless there is immediate and vigorous first aid or medical attention. Large doses drugs with fifth of whisky and suicide note. Hanging attempt, with patient found cyanotic.10.0 Death almost certain. Use of shotgun. Drowning self at midnight in a lake. Survival is accidental.

Suicide Attempts

Most don’t die in their attemptYouth: 100 -200 attempts per 1 completionElder: 4 attempts per 1 completionAverage: 25 attempts per 1 completion5 million Americans have attempted (est.)Reporting problem - under reporting- unknown (don’t ask, don’t tell)

Source: www.suicidology.org and AMA…

http://www.suicidology.org/

Suicide and Homicide

More homicides or suicides per year in the US?

Is there any overlap between homicide and suicide?

Facts you Need to Know

If a man calls, take him seriously, he may have a gun in his hand..

Boys, teenaged boys, young men 18-25Highest tally of total death: men in middle yearsOld white males are the highest risk group- 79% use a firearm (lethal planners)- They know how to do it and plan carefully- They avoid rescue

“If a woman calls about a man, take her even more seriously.”

Cold Sober Suicide

Where alcohol and other drugs on board contribute to greatly to suicide risk in younger people, among men over 65 only 9% had a BAC greater than .8

Source: National Violent Death Surveillance System

Facts you need to know…

Suicide risk rises with age for white males, not for men of colorResponsibility for one or more children is a powerful protective factor against suicide in women (Sweden)Contact with a healthcare provider does not confer protection…. and neither does recent psychiatric hospitalization.Most suicides occur with weeks to months of last contact AND risk rises after discharge!

References on Primary Care and Suicide

Andersen, S.M., and Harthorn, B.H. (1989). The recognition, diagnosis and treatment of mental disorders by primary care physicians. Medical Care, 27: 869-886.Coombs, D.W, et al. (1992). Presuicide attempt communications between parasuicides and consulted caregivers. Suicide and Life Threatening Behavior, 22: 289-302. Hirschfeld, R., et al. (1997). The national depressive and manic depressive association consensus statement on the under treatment of depression. Journal of the American Medical Association, 277(4): 333-340.Miller, M.C., Paulsen, R.H. (1999). Suicide assessment in primary care settings. In Jacobs, D.G. (ed.). The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco: Jossey-Bass.Orleans, C.T. (1985). How primary care physicians treat psychiatric disorders: a national survey of family practitioners. American Journal of Psychiatry, 142(1): 420-432.Rand, E.H., Badger, L.W., and Coggins, D.R. (1988). Toward a resolution of contradictions. Utility of feedback from the GHQ. General Hospital Psychiatry, 10: 189-196.Moscicki, E.K. (1999). Epidemiology of suicide. In Jacobs, D.G. (ed.). The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco: Jossey-Bass.Gliatto, M. F. and Rai, A. K. (1999). Evaluation and treatment of patients with suicidal ideation. American Family Physician 59: 1500-1506.Katon, W., and Schulberg, H.C., (1992). Epidemiology of depression in primary care. General Hospital Psychiatry. 14: 237-247.Kaplan, M.S., Adamek, M.E., and A. Calderon. (1999). Managing Depressed and Suicidal Geriatric Patients: Differences Among Primary Care Physicians. The Gerontologist: 39(4):417-425.Uncapher, H., Arean, P.A. (2000). Physicians are less willing to treat suicidal ideation in older patients. Journal of the American Geriatric Society 48: 188-192.

Suicide Prevention is Violence Prevention

DOMESTIC VIOLENCE, SUICIDE AND HOMICIDE* DV victims make more suicide attempts (20 to

26%).* Violent families contribute to youth suicide. * Violent people have a history of self-destructive

behavior (30%).* Double suicides are often motivated by the

couples fear of separation and the fantasy that they can remain together in death.

* Abusive men who kill their wives and lovers usually do so in response to the woman’s attempt to leave.

Intimate Partner Violence• Males who threaten suicide in an intimate partner

violence situation are at greater risk for murder-suicide.

WSDVFR finding: “Abusers were suicidal in 35% of domestic violence fatalities overall (this includes cases where no homicide occurred), and in 31% of the cases in which a homicide was committed.”

US AIR FORCE: • Suicide rate down 33%,• Homicide rate down 52%• Serious DV rate down 54%

Suicide Prevention IS violence prevention!

Survivors of Suicide

6 blood relatives directly affected by each suicide1 of every 62 of us is a survivorThis number does not include colleagues, co-workers, friends, team or school mates and ex spousesOne suicide every 18 minutes = 6 new survivors Suicide risk is greater in survivors (e.g., 4-fold increase in children when a parent dies by suicide)If roughly 30,000+ Americans die by suicide each year leaving 180,000 blood relative survivors, how many have died by suicide since 9/11, and how many new survivors are there?

GOOD NEWS!

A national suicide prevention movement has begunResearch, medicine and political will are buildingStigma, funding, and lack of awareness remainLeadership has emerged: NIMH, CDC, National Council for Suicide Prevention, AAS, AFSP, SPRC, SAVE, etc.U.S. Air Force success story is outThe majority of Americans believe we should fund more research and believe many suicides are preventable (SPANUSA research)

Suicide Risk and Risk Management

What you need to know….

Suicide Risk Assessment

Prediction is complex and difficultPrognosis vs. predictionChallenge of a low probability eventBehavior is threshold sensitiveBehavior is context sensitiveBehavior relationship sensitiveSummation of risk factors not helpfulScreening tools can get you in trouble

(prediction is best done in reverse)

ENVIRONMENTAL RISK

FACTORSAttempts Completions

Seasonal Variations Unknown Jan-Feb, March Peak

Weekly Unknown High Midweek

Geography High on both Same

War Unknown Inverse

Unemployment:

Chronic Unknown No AssociationSudden Direct Direct

* Source: Harvard School of Public Health, 1998

SUICIDE CRISIS EPISODE

Stable Stable

Days Hours Days

Years Years

Crisis Peaks

Crisis Begins

Hazard Encountered

Risk Imminent

Crisis Diminishes

Plus or minus three weeks

THE LETHAL TRIAD

UPSET PERSON

FIREARM ALCOHOL

When these three are present-the risk of violence is high.

Dr. Tom Joiner’s Interpersonal Theory of Suicide

Two major components associated with suicide and serious attempts– The desire to die and – the capacity for self harm

Two elements within the desire to die– Perceived burdensomeness– A sense of thwarted or low belongingness

Serious Attempt or Death by Suicide

Those Who Desire Suicide

Those Who Are Capable of Suicide

Sketch of the Theory

Acquired Capacity for Suicide

Suicidal behavior is not just about the desire to die

It requires the capacity to inflict self injury

The Acquired Capability to Enact Lethal Self-Injury

This capacity is acquired over time

Accrues with repeated and escalating experiences involving pain and provocation, such as

– Past suicidal behavior, but not only that…– Repeated injuries– Repeated witnessing of pain, violence, or injury

(e.g., physicians, EMS, ED nurses, law enforcement personnel, and combat soldiers)

– Any repeated exposure to pain and provocation.

The Acquired Capability to Enact Lethal Self-Injury

According to Joiner, with repeated exposure, one habituates – the “taboo” and prohibited quality of suicidal behavior diminishes, and so may the fear and pain associated with self-harm

The Many Paths to SuicideFundamental (distal)

Risk FactorsAcute (proximal) Risk Factors: triggers/last straw

Cause of Death

Crisis in Relation

Loss of Freedom

Fired/ Expelled

Illness

Major Loss

?

Poison

Gun

Hanging

Autocide

Jumping

?

Increasing Hopelessness

Contemplationof Suicide

as Solution

WA

LL

OF

RE

SISTA

NC

E

Genetic Load

Sex

GLTBRace

Age

Drugs or

Alcohol

Biological

Child Abuse

Loss of Parent

Culture Shock/Shift

ValuesReligionBeliefs

Season of year

Geo-graphy

Model for

Suicide

Personal/Psychological

• All “Causes” are real.• Hopelessness is the common pathway.• Break the chain anywhere =

prevention.

Environmental Urbanvs.

Rural

-- Sobriety --

Best Friend(s)

SafetyAgreement

Treatment Availability

Pet(s) Calm Environment

ReligiousProhibition

AA or NASponsor

Difficult Accessto means

A sense ofHOPE

Positive Self-esteem

Fear

Job Security orJob Skills

Support of significant other(s)

Counselor or therapist

Medication ComplianceGood health

Responsibilityfor children

Others?

Wall of Resistance to Suicide

Protective Factors and Buffers Against Suicide

Duty to others

Nature of the suicide

Psychic suffering (Psychache)HopelessnessUnbearable mental anguishCognitive constrictionGrossly impaired problem solving abilityFeeling a burden to others Thwarted belongingnessAcquired capacity for self-injury

BASIC CONCEPTS ABOUT SUICIDEÖSuicide is always multi-determined.

ÖSuicide prevention must involve multiple approaches.

ÖMost suicidal people do not want to die.

ÖSuicidal people want to find a way to live.

ÖAmbivalence exists until the moment of death.

ÖThe final decision rests with the individual.

ÖReduce risk factors and you reduce risk.

ÖEnhance protective factors and you reduce risk.

End Module

Questions

The Relationship of Mental Illness and Substance Abuse to

Suicide…

Preventing suicide is largely about identifying and treating mood disorders, alcoholism and co-occurring disorders

WHO aims to target:- Mood disorders- Schizophrenia- Alcoholism

World evidence for treatment effectiveness suggests suicide rates can be substantially reduced in all these categories… if we can find them before they die

Source: www.who.org

Is Suicide Primarily: “Mental Health Territory?”

Lifetime Suicide risk for Schizophrenic, Affective and Addiction Disorders:

Method: review of 83 mortality studies:

– Schizophrenia…………4%

– Affective Disorders……6%

– Addiction Disorders…...7%

Inskip HM: Br J Psych 1998

Epidemiology: Interesting but not clinically useful…

Suicide rates vary across cultures, racial groups, age groups, time and by geography.

Major risk factors: Mental disorders, hopelessness, impulsive and/or aggressive tendencies, history of trauma or abuse, major physical illnesses, previous suicide attempt, family history of suicide, etc. (see NSSP for complete lists of risk and protective factors)

What you need to know: 90-95% of all completed suicides have an Axis I disorder…BUT – most people with these illnesses DO NOT die by suicide.

General Neurobiology of Suicide

® Reduced serotonin function in suicide, especially in suicides of high lethality or with considerable planning

® Depletion of essential neurotransmitters (including dopamine and serotonin) may be the common clinical pathway for suicidal thinking, feeling and behaviors

®Genetic studies inconclusive to date

®Familial patterns of suicide suggest biological factors may influence risk.

From Joseph Coyle, MD,Harvard Medical School, 1997

Specific neurobiological changes in severe suicidal depression

Loss of gray matterImpaired prefrontal cortical response to serotonin releaseDopamine deficitSerotonin hypofunction in the PFC correlates to higher suicidal intent and planning and lethality of suicide attempt

MDD AND SUICIDE

Lifetime risk: 2- 6% (lifetime risk)98 % of completers are seriously depressed Most die while off medication.Adherence to meds is essential to safety.For severe, agitated and suicidal depressions, electroconvulsive therapy may be the best choice.

Family/patient education: MMD is a potentially fatal illness and death is a possible result of not following medical advise.

Benzodiazepines are often underutilized (more later)

Pharmacotherapy for depression

PET scan depicts a depressed patient’s brain prior to treatment, after successful treatment , scan reveals greatly increased activity in the prefrontal cortex

Warning, do not use the brain on the left to make a life or death

decision….

A note on antidepressants

TCAs deadly in overdose

SSRI’s not deadly in overdose

Lot’s of TCAs prescriptions = more suicides

Lot’s of SSRIs prescriptions = fewer suicides

(EU, Australia, Scandinavia, USA)Sources:

Grunebaum, et al, J. Clin. Psychiatry, 2004

Gibbons, et al, Arch Gen Psychiatry, 2005

Gibbons, et al, Am J. Psychiatry, 2006

BIPOLAR DISORDER & SUICIDE

¨ #1 cause of death, 1 to 2% per year.¨30 studies 9 to 46% x = 19%.¨Attempts

àMajor Depressive Disorder = 20%àBipolar Disorder = 25%-50%àGeneral Population = 1%

¨Highest risk windowsàEarly in illnessàIn denial phaseàDuring mixed statesàWhile experiencing depressive mania

K. R. Jamison, 1997John Hopkins University

1st line intervention for suicidal bi-polar patients

- Lithium appears to decrease aggression and impulsivity

- Psychotherapy and mood stabilizers prevent suicide better than mood stabilizers alone.

Lithium has pronounced anti-suicide effect (600 fold impact)

Lithium works best for those who won’t take it; when they do take it, therapeutic impact is significant

SUICIDE AND SCHIZOPHRENIA- Ten to 15% complete suicide (best estimated

of Lifetime risk: 5%). Leading cause of death in patients under 35.

- Negative symptoms associated with increased risk.

- 20 to 40% make a suicide attempt.

- Finland National Study (1997) - 7% of all suicides met DSM-IV criteria for schizophrenia (N=92). Of these 92, 64 were also depressed.

- Suicides occur during active phases of the illness

M.T. Tsuang, MD,

Harvard Medical School, 1998

Suicide and Schizophrenia

Inadequate pharmacotherapy contributes to higher suicide rates for schizophrenics.

Major risk factors: young age, early stage of illness, substance abuse present, college education, multiple episodes of psychosis, living alone, history of previous attempt.

Improving on medications is the most dangerous time.

Suicides occur after discharge and in the first year of follow-up from index illness.

A note on Clozapine

Most effective for negative symptoms

Best for Rx resistant, has antidepressant and mood stabilizing effect

Clozapine reduced suicide events by 25% compared to olanzapine

Clozapine 2 yr NNT of 13 to prevent 1 attemptSource: Meltzer et. al. 2003/Health study research

NEJM,1989.

Or is Suicide also:Addictions Territory?

Alcohol strongest predictor of completed suicide over 5-10 years after attempt, OR= 5.18…vs. demog or psych disorders ( Beck J Stud Alc 1989)

40-60% of completed suicides across USA/Europe are alcohol/drug affected (state variable). Editorial: Dying for a Drink: Brit Med J. 2001

Higher suicide rates (+8%) in 18 vs. 21yo legal drinking age states for those ages (Birckmayer J: Am J Pub Health 1999)

Alcohol Abuse and Suicide

Major risk factors: male, long-term drinker, co-morbid psychiatric disorder.

Intoxication impairs judgment and increases impulsivity and aggressiveness

Co-morbidity increases risk

Highest risk group: MDD and alcoholism.

Alcoholism erodes protective factors: loss of job, health, home, money, family & friends

Alcohol myopia: inability to access the consequences of one’s actions (the stupid effect)

Sources: NIMH, Dying for a Drink, BMJ Oct 2001

IP OP MM Detox0%

10%

20%

30%

40%

25%20% 18%

20%

17%13% 11% 13%

% Thoughts % Attempted

Lifetime Suicide Thoughts/Attempts

ASI data, TRI database-04

N=60,952

Skip the booze and junk

Copyright, 2004, CNS Productions, Inc.

28

Chronic Alcohol Abuse Heroin AbuseChronic Alcohol Abuse Heroin Abuse

What do we know about Suicide in Prospective Age-Matched Alcoholic

Populations

4.5% of alcoholics attempted suicide within 5 years of DX – ( age 40.. n=1,237)

0.8% in non-alcoholic matched comparison group – ( age 42..n=2,000)…

p< .001………..7X increased risk

Preuss/Schuckit Am J Psych 03

Methamphetamine Users (n= 1,016) LIFETIME SUICIDE ATTEMPTS and BEHAVIOR PROBLEMS

ASI Item Overall Males FemalesTest

Statistic*

Attempted Suicide (%) 27% 13% 28% 35.42**

Violent behavior problems (%) 43% 40% 46% 3.29***

Assault Charges (mean number) 0.29 0.46 0.15 4.46**

Weapons charges (mean number) 0.13 0.21 0.07 4.09**

*Mantel-Haenszel chi-square was used to test differences in proportions by gender, df=1; Student’s two-group t-test (two-sided) was used to test differences between males and females in continuous dependent variables reflecting the number of charges, df=1013. **p < 0.00001 ***0.1 < p <0.05 Zweben, et al., 2004

Skip the Meth

Copyright, 2004, CNS Productions, Inc.

27Normal BrainNormal Brain Methamphetamine AbuseMethamphetamine Abuse

Substance Induced Depression: Severity/Dangerousness

Henriksson, et al (1993)- 43% of completed suicides had alcohol dependence. 48% of these were also depressed. 42% had a personality disorder.

Elliot, et al (1996)- patients with medically severe suicide attempts had a statistically higher prevalence or substance-induced mood disorder.

Pages K et al (1997)- Higher degrees of Sub + Dep related to higher severity suicide ratings

Transient acute depression

Intense, short-lived depression is prevalent among treatment-seeking people who abuse cocaine, methamphetamines, and alcohol. Does this depression increase suicide risk?

Brown et al., 1995; Cornelius, Salloum, Day, Thase, & Mann, 1996; Husband et al., 1996).

Traumatic brain injury

Blast is the most common wounding etiology our returning war fighters50-60% of those exposed to blasts sustain a brain injury (Walter Reed Army Medical Center)Depression, PTSD and alcohol use commonSimpson & Tate post-injury TBI community sample study (2002):

- 23% had significant suicidal ideation - 18% made a suicide attempt

Life time risk of suicide 3-4 times higher

PTSD and Suicide

Research: Positive correlation between PTSD and suicide

Some studies suggest that suicide risk is higher due to the symptoms of PTSD; others claim risk is higher due related psychiatric conditions

Intrusive memories, high arousal & low avoidance increase risk of suicide ?

PTSD

Or, is it the co-occurring depression and/or alcohol use?Risk factors: male, alcohol abuse, older, family history of suicide, homeless, single, with firearmHighest risk: multiple combat wounds and/or hospitalized for injury + guilt over combat behavior

Source: The Relationship Between PTSD and Suicide, William Hudenko, Ph.D. VA – National Center for PTSD

FIVE ACUTE SUICIDE RISK FACTORS

Severe psychic anxiety/turmoil

Incessant rumination

Global insomnia

Delusions of gloom and doom

Recent alcohol use (with or without alcoholism)

Jan Fawcett, M.D., 1997 (replicated in 2003 with 76 inpatient deaths)

PSYCHIATRIC COMORBID TRANSIENT ILLNESS PSYCHOLOGICAL STATES

Schizophrenia Agitation

Depressive Disorder Perturbation

Bipolar Disorder Psychic Pain

Panic Disorder Hopelessness

Substance Abuse Disorder Dopamine Deficit

Personality Disorder Serotonin Deficit

Co-morbid Physical Illness Alcohol Myopia

DISEASE MANAGEMENT MODEL FOR SUICIDAL PATIENTS

Common Chemical Pathways for Suicidal Acts?

Alcohol in the bloodstream

Low serotonin levels

Impaired dopamine function

What can we do?

Do we know how to sober people up?Do we know how to treat anxiety?Do we know how reduce psychic pain?Are there effective treatments for agitation?Do we know what to do about serotonin deficits? CBT for depressive hopelessness?DBT for Axis II consumers

Good news! Treatment works

Cognitive therapy reduces youth suicide attempts by 50% (Brown, et al, Aug 3, 2005 JAMA). Youth Suicide Rates Lower in Counties with High SSRI Use (Gibbons, et al, Am. J. Psychiatry 2006)Several therapies are being adapted specifically for suicidal patients.. MI, CBT, IMPACT and Problem Solving Therapy

Limitations: 18-month follow up and correlational data only

Good news The Gotland Study: PTD

A primary care physician training program to increase early recognition and treatment of depressive disorder; suicide rates went down in the follow up years…

“This finding strongly suggests that the significant decrease in the suicide rate after the PTD programme is a direct result of the robust decrease in depressive suicides of the area served by trained GPs.”

Source: Rihmer Z, Rutz W, Pihlgren H., J Affect Disord. 1995 Dec

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Rihmer%20Z%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Rutz%20W%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Pihlgren%20H%22%5BAuthor%5D

Depression/suicide screening in the Henry Ford Health Systems

Zero is perfect number of patient suicides

Perfect Depression Care initiative

Relies on a “shift in thinking, rather than on costly resources or a surge in clinical staff”

Six steps: set goal, engage patients, improve quality, monitor, report, etc. (read)

If you build it, they will come…

Results? 75% reduction in suicide

2002-2005: baseline 87/100K suicides

4 years in: baseline dropped to 22/100K

In the past two years, or the last 10 consecutive quarters, the department has not seen one patient suicide.

U-Tube: http://www.youtube.com/watch?v=gCvNnIO-shE

Source, Ed Coffey, MD, CEO and Joint Com.

http://www.youtube.com/watch?v=gCvNnIO-shE

Dr. Ed Coffey…

"There's nothing unique about the strategies. Everyone would say they're doing the same thing. We assess the risk and do everything we can do to lessen that risk.”

Everyone gets training and must be competent (100%) on exams.

More good news!Addiction treatment works

Cohort suicide attempts

year prior year after

Adults

> 25 yo (n=3,524) 23%...........................4%

18-24 yo (N=651) 28%...........................4%

Adolescents (n=236) 23%...........................7%

Karageorge: National Treatment Improvement Evaluation study 2001

Take home messages….

Most dangerous diagnosis: alcoholism and major depressive disorder… Am. Journal of Psychiatry, 1998.

3 Common clinical pathways: serotonin deficit, dopamine deficit, and alcohol in blood stream

Co-occurring disorders kill

There is no safety without sobriety…

Treatment works!

Discussion

Questions?

Risk Rating Exercise

Compare yourself with other judges

Rate each of the following on a scale of 1 to

(1= no risk; 7 = high risk)Stelmachers & Sherman

CASE #1

A 21 year old male, foreign graduate student was brought to Crisis Intervention Center by friends and a pastor. After informing his friends that he planned to jump off a bridge, he actually went there and had to be physically restrained from jumping. He had written several suicide notes, one willing his computer to a friend, another to a different friend stating that the patient would be dead by the time his note was opened.

CASE # 1 Continued

The patient described himself as being quite depressed, with low energy, poor sleep and appetite, and persistent suicidal ideation. The precipitant seems to have been his girlfriend’s breaking off their engagement four days ago. He has a psychiatric history of several years, but refuses to reveal any details. He exhibits some grandiosity, paranoid mentation, anger, agitation and irritability. He appears somewhat manic but not depressed. He denies any acute plan to commit suicide and is threatening to sue the CID for having been detained.

Risk Rating

Rating: High Risk

Mean 6.21

SD. 0.86

Case # 2

A 16-year-old Native America female presented as a self-referral following an overdose of 12 aspirin tables. Patient reports that she could not tolerate the rumors at school that she and another girl are sharing the same boyfriend.The patient denies being suicidal at this time (“I won’t do it again; I learned my lesson.”)

She reports that she has always had difficulty expressing her feelings. In the interview she is quiet, guarded and initially reluctant to talk.

Diagnostic impression: adjustment disorder

Risk Rating

Rating: Low Risk

Mean: 2.25

SD: 1.29

Case # 3

A 39 year old white male was referred from the Emergency room. Patient was in the process of overdosing when he was called by a friend, who arranged for the ambulance to bring him to the CIC. The patient took 10 or 15 aspirin tablets and 72 over the counter sleeping pills. He had written a long suicide note bequeathing belongings, expressing guilt about not doing well on his job and feeling hopeless about a “hereditary thinking disorder.”

Case # 3 continued

He feels that no one can help him and suffers from low self esteem. Says, “I’m a misfit.”

Three nights ago he had also made a suicide attempt with Navane and aspirin but woke up by himself in the morning. He lives by himself. There was no obvious immediate precipitant, but the patient’s mother had died six months ago. He is currently in therapy and has a psychiatrist.

Risk Rating

Rating: High Risk

Mean: 6.58

SD: 0.61

Case # 4

A 38-year-old man with a chronic and persistent, severe infection in his right hand is evaluated to be moderately depressed. Prognosis for his infection is not good and he has been struggling with feelings of hopelessness regarding his hand.

There is no family history for suicide, mental illness, mood disorders or alcoholism. This man is neither alcoholic nor drug dependent, has a high IQ and has never been in trouble emotionally. He is cooperative during the interview, but distant. His family remains greatly concerned.

What you need to know….

This troubled man has been training to be a concert pianist for the past 25 years.

Case # 5

A 30-year-old married female is discovered to be having an affair by her husband (a minister). After her husband’s learning of her indiscretions, she requests an emergency evaluation for treatment. She states she has not been depressed, but does feel panicky. She states her husband has a history of losing his temper and she is afraid of him. However, she seems resourceful, intelligent and articulate. There are no children in the family. She does not have a history of prior suicide attempts, but reports she is now thinking about it. She reports she and her husband have continued having sexual relations throughout the period of her affair.

What you can’t know, but should always plan for….

Two days before her scheduled counseling appointment, her lover tests positive for HIV and calls her husband to inform him of his exposure….

Things to Keep in Mind

The absence of SI does not equal no suicide risk

The denial of SI does not equal no suicide risk

Once suicide been considered a solution, the problem it would solve can suddenly become much bigger

Always determine the psychological, social, emotional, and environmental context and crisis in which a suicidal person is trapped, or feels about to be trapped.

Things to keep in mind….

Wall, Platt and Hall, 1999 study of 100 successive suicide attempters:- 83 had been seen within one month by healthcare providers (PCP and mental health), yet only 28 had be asked about suicide.

You can’t assess risk you don’t know is there, and your referral source PROBABLY hasn’t asked!

Don’t ask, don’t tell, don’t work….

The 10 Top Reasons never to ask your patient if they’re suicidal

Reason # 10: My schedule is already full next week if they need extra sessions.



Reason # 9: If they were really suicidal, they would say so.




Reason# 8: There’s no room on the form.




Reason# 8: There’s no room on the form.

Reason # 7: I’m not sure I like this patient very much.




Reason# 8: There’s no room on the form.Reason # 7: I’m not sure I like this patient

very much.Reason # 6: The managed care company

doesn’t want to know.


Reason # 5: Denial in my line of work is underrated, what I don’t know can’t hurt me.



Reason # 4: It’s already 11:45 and I have plans for lunch.




Reason # 3: I probably couldn’t get them into a hospital anyway.




Reason # 3: I probably couldn’t get them into a hospital anyway.

Reason # 2: Nothing I learned in graduate school says I have to.

And the # 1 reason not ask our patient if he or she is suicidal?

MY GOD THEY MIGHT SAY YES!

End Module

Questions

Avoiding Suicide Malpractice

Highlights only – full 2-hour course now available online at www.qprinstitute.com

Taught by lawyer and psychologist

http://www.qprinstitute.com/

Common Suicide Malpractice Errors

Type 1: Failure to detect and assess suicide risk

Type 2: Failure to manage and treat properly (sub standard care)

Type 3: Postvention failure – failure to address survivor needs“

Who will sue you?

An uninformed family is a potentially litigious one -

especially if not comforted after the suicide.”

Source: QPR Institute, 2001

Best Defense?

1. A well-trained, skilled clinician (with documented specific training)

2. Sensitive and caring staff with client and family (they don’t sue you if they like you)

3. Everyone took reasonable and competent steps in providing assessment and care

Worst Defense?

1. Untrained, unskilled and unprofessional staff

2. Perceived as uncaring by client and family

3. Evidence of sloppy work

Avoid suicide malpractice every time!

Get appropriate training and keep records of same

Routinely query about suicide risk

Document your risk assessment

Carry out a “best practices” treatment plan

Team up and chart

Document why you did what you did, and why you didn’t do something even your mother would think you should do.

"If the docs took the course, followed the course in their practice, documented their actions, and still had a suicide, they would not need insurance if I reviewed the file. I have never sued a mental health practitioner with a documented file.”

Skip Simpson, Attorney at Law(Jedi Knight of Suicide Malpractice –

88%)

“If it isn’t written down, it didn’t happen.”

T. Gutheil, 1980

***Twin pillars of defense:

Consultation and documentation

True story

My son died by suicide in 1993 and in the process of suing the hospital and the doctor, the last professional to see my son for therapy was a Ph.D. in Psychology. When this person was deposed, he reported that he never asked him if he was suicidal (Todd was two days post discharge from a suicide attempt) and said that 'he was a bright young adult, if he was suicidal, he would have told me.' Two days later, Todd hung himself. I won the case out of court without going to a jury!

Sherry Bryant, LCSW, CADC, LMFT

End Module

Questions

Lunch?

CURRENT THINKING ON SUICIDE AND RISK

¨ The greater the number of losses, the greater the risk.

¨ Personally humiliating events.

¨ No good evidence for sexual orientation as an independent risk factor for suicide.

¨ Treatment prevents suicide.

Eve Morscicki, NIMH, 1997

Suicide Risk Assessment: What you Need to Know…

Screens for suicide produce large numbers of false positives (will not die by suicide)Positive screens require assessmentsNo useful psychological tests or methods to predict suicide attempt (NIMH)Summation of risk factor approach too nonspecific and weak in predicting individual suicide

Prediction vs. Standard of Care

You are not required to predict the future, but you are required to try (assess risk).

Note: 40% of clinical decisions at major academic medical centers are not based on research evidence (Gray, Evidence Based Psychiatry, APA 2004)


¨ The greater the number of losses, the greater the risk.

¨ No good evidence for sexual orientation as an independent risk factor for suicide.

¨ Personally humiliating events may trigger suicidal behavior in non-mentally ill people

¨ Single greatest risk: untreated mental illness

Eve Morscicki, NIMH, 1997


¨ Necessary condition + trigger(s) push suicide threshold.

¨ Distal vs. Proximal & Trait vs. State variables.

¨ Halt (hungry, angry, lonely, tired).

¨ Absence of a psychiatric diagnosis does not equal mental health.

¨ Co-morbidity is the single greatest risk.

CURRENT STATUS OF SUICIDE RISK ASSESSMENT

¨ National Survey: Almost all clinicians rely on clinical interview (Jobes, Eyman & Yufi, 1995).

¨ No known test will predict suicide.

¨ Screening inventories useful but…. Beck Hopelessness scale the best life long predictor

¨ Risk detection is job one.

¨ 75% of suicides see a physician within a week to a month before their death (NIMH: opportunities missed)

¨ Current screening methods produce large numbers of false positives.

¨ Summation of risk factor approach:-not clinically useful-too nonspecific to be helpful-inefficient and weak in predicting

individual suicide

¨ 67% - 91% of completers made no previous attempt (Coe, 1963 & Dorpat, 1960).

¨ Lot’s of risk goes unrecognized…

CURRENT STATUS OF SUICIDE RISK ASSESSMENT

UNRECOGNIZED RISK

¨ 60% of suicide completers had no contact with a mental health professional and no prior suicide attempt.

¨ 60% to 90% of all suicide completers had communicated explicit intent to a significant other during the period prior to death.

¨ 75% to 80% had a non-psychiatrist physician contact within six months.

¨ 93% of completers had an Axis I diagnosis.

¨ One-sixth of all completers are in current treatment with a mental health provider

Clark and Fawcett 1991

What do we know?

Surveys show most clinicians use an interview format, not psychometrics

There is no consensus practice standard or tool (Simon & Shuman, CNS, 2006)

Review the APA’s Practice Guidelines for comprehensive review (Jacobs, et. al, 2004)

Get some training….

Raising the bar beyond the current standard of practice

You are required to perform an adequate assessment, not to predict suicide.

The standard of care is legally defined, not ideal (statutory language varies state to state).

Standards of care are minimum, not maximum

Medical custom vs. reasonable & prudent

WE CAN DO BETTER…

Worst clinician in the world!

- Suicide is not spoken here, so no query was ever made- Assessment appears skimpy, e.g., “Denies SI, HI and CFS.” - Skimpy assessment + reliance on no-suicide contract (“He promised me he wouldn’t.”)- Assessment present but written in Sanskrit (inscrutable handwriting)- Assessment is not communicated to others

JCAHO and Suicide

JCAHO Reported 501 Inpatient Suicides From 1995 To 2004 And 56 In 2005

Inpatient SuicideMost common sentinel event reported to the JCAHO

Since 1996*-- 415 (14%)

Method:– 71% Hanging– 14% Jumping

Factors

87% Deficiencies in physical environment

83% Inadequate assessment

60% Insufficient staff orientation or training

Psych Hosp; 43

Psych Ward; 23

Med/Surg; 15

ED; 3Res Care; 12

Long-term; 3

*Sentinal Event reporting begain in 1996. Source: Reducing the Risk of Suicide. JCAHO, Joint Commission Resources, Inc. 2005

Where Inpatient Suicide Occurs

Best clinician in the world!

Treats all threats as genuine (until proven otherwise)

Gets all the data and the PINS

Understands the CONTEXT

Assesses clinical status thoroughly

Documents all actions taken and why

Documents all actions NOT taken and why

Communicates the risk to others

Limitations of the clinical interview in suicide risk

assessment

Update and new research

Current practice standards

Clinicians rely on their clinical interviewing skills to understand the patient’s reality

The patient’s reality is often distorted by CNS dysfunction

“Facts” elicited from distressed patients may be interesting and useful to plan treatment, but they may not be an accurate reflection of dynamic reality

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

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

Fear that full disclosure will prevent discharge from hospital

Fear that full disclosure will lead to arrest and possibly incarceration

Fear that full disclosure of suicidal desire and intent will lead to unwanted rescue

Why not “tell all?”

Fear that revelation of access to a firearm or drugs may implicate personal or third party illegal ownership of same

Fear that the interviewer is neither benevolent nor trustworthy

Fear that revelation of a suicide plan may expose a double suicide, suicide pact or planned murder-suicide

Fear that disclosure of suicidal desire, intent, rehearsal or past suicide attempts will lead to shame and censure or job denial or loss

Better solution

Do not rely on a single reporter

Do not rely on a single data source

Do rely on multiple observers

Interview everyone possible (conduct a psychological autopsy in reverse)

What you don’t bother to learn now, you have to learn later (in court)

It’s what they do, not what they say

End Module

Please read your QPRT User’s Manual/Handouts carefully….

Always do better on the competency quiz that the lawyer who is suing you…..

This is not an MRI of the lawyer about to sue you…

End Module

Questions

The QPRT Risk Assessment Method

QPRT recognition 1999-2007

1998 J.J. Negley Associates, Inc. Presidents Award for Avoiding Suicide Malpractice. $15,000 NCBHC

Joint Commission 3 patient safety publications

Devereux Foundation adoption (1999)

APA Patient Safety Task Force (2002)

TIP 42 (2005)

¨ Developed by clinicians for clinicians

¨ Brief and user friendly

¨ Standardizes suicide risk data collection

¨ Improves triage decision making

¨ Reviewed and contributed to by nationally and internationally known suicidologists

¨ Heavily field tested in outpatient, emergency and hospital settings

¨ Offers adult/older adult, pediatric and hospital versions

QPRT Benefit Summary

¨ Routinely detects the presence of suicidal ideation, feelings, plans and past attempts

¨ Nests well with other risk evaluation methods

¨ Generic and fits into any medical or psychological record

¨ Integrates risk assessment with risk management

¨ Enhances standard of care

¨ Is accepted by patients (89% report satisfaction with interviewer’s skill and comfort)

¨ Is accepted by clinicians (94% believe it improves their standard of practice)

¨ Reduces exposure to suicide malpractice

QPRT Benefit Summary

The QPRT interview is not:

A substitute for psychiatric diagnosis

A treatment plan

A substitute for a comprehensive mental health examination

Follow along….

Please take your sample QPRT or one from your folder and follow along and, if you like, make notes…

No relationship, no data

Without a “therapeutic alliance” with the suicidal patient little information of real value will be learned from any interview protocol, including this one

The strength of this alliance determines how well this protocol works to assess suicide risk and intervention results

The QPRT interview is:

A tactical structured interview protocol designed to obtain critical, dynamic suicide risk and protective factor informationA tool to help determine near-term suicide risk A strategic intervention designed to reduce immediate risk of suicide through empathic inquiry and enhance suicide protective factors

The QPRT interview may not be useful with:

Actively psychotic patients

Patients so depressed they can barely speak, or so manic they cannot be engaged

Intoxicated patients

Delusional patients

Highly impulsive patients, especially if on drugs and/or alcohol

Patients suffering from severe dementia or obvious cognitive impairments

Asking the S Question: Samples

“You know, when people are as upset as you seem to be, they sometimes wish they were dead. I’m wondering if you’re feeling that way, too?”“You seem very unhappy. Have you had any thoughts of death or suicide?”“Suicidal thoughts are a common symptom of depression; have you had been depressed lately?”“Have you been suicidal or have you been thinking about suicide?”

Sample S Questions

“Are you considering ending your life?”

“Have you ever wished that you were dead?”

“Are you thinking about killing yourself?”

“Have you thought about suicide in the past two months?” (Sometimes suicidal people will tell you about how they felt last week, but not today.)

Wrong way to ask S Question

“You’re not thinking of suicide, are you?”

…or any variant question which asks for a denial….

QPRT SUICIDE RISK MANAGEMENT INVENTORY

Patient Name Case Number DateQuestioned the patient about thoughts of death or suicide: Yes No Suicidal thoughts/feelings present: Yes No If no, review and initial statement on following page.

If YES, document: WHAT IS WRONG?

WHY NOW?

WITHWHAT?

WHERE AND WHEN?

WHEN AND WITH WHAT IN THE PAST?

WHO IS INVOLVED?

WHY NOT NOW?

Q

WHAT’S WRONG?

What You Should Learn:

Explanation of the reasons for suicide

Problem(s) that suicide would solve, such as being a burden on others

How this person solves problems

Eliciting the narrative..There is therapeutic value in telling the story – and we mean the “whole story” behind the ideation or attempt…

The clinician must simply say, “Begin wherever you like…”

Interrupt the patient’s story only for clarification

Sample Questions

“Okay John, why don’t you tell me what’s wrong with your life right now?”

“Audrey, could you tell me what led up to this? Begin anywhere you like.”

“We’ve got some time to talk. I’d very much like to hear your version of what’s wrong right now and this crisis came to be.”

Key Points for What’s Wrong?

Most suicidal people need to talk. Others may not be listening, but now you are. Telling their story produces relief.Active listening without interjecting judgments or opinions is essential to encourage full disclosure.Telling one’s story may help restore the person’s ability to think more clearly and cope more successfully.

Expect Common themes (suicidal desire and intent)

– Feels hopeless and depressed (clinical depression is the most common cause of suicide)

– Feels isolated and alone

– Has lost job or major relationship or a multiple of losses

– Feels overwhelmed, angry and upset

Common themes

– Feels like a burden on others

– Financial problems with no escape

– Fears being humiliated, e.g., arrested for a sex crime

– Has serious problems at work

QPRT SUICIDE RISK MANAGEMENT INVENTORY

Patient Name Case Number DateQuestioned the patient about thoughts of death or suicide: Yes No Suicidal thoughts/feelings present: Yes No If no, review and initial statement on following page.

If YES, document: WHAT IS WRONG?

WHY NOW?

WITH WHAT?

WHERE AND WHEN?


WHO IS INVOLVED?

WHY NOT NOW?

Q

WHY NOW?What you should learn

Recent history of recent or anticipated real or imagined losses or rejections. Trigger event(s) - separation from spouse, loss of home, domestic violence, anticipated loss of job, any changes creating a sense of burdensomeness on others, or that causes isolation from one’s primary group.Onset of sleeplessness, depression, loss of appetite, relapse into drug or alcohol use, anxiety, panic attacks, or other symptoms of acute psychological distress.

Sample Questions

“Robin, what has changed such that you are considering suicide now?”“It sounds as though this relationship has been difficult for a long time. What’s different for you now?”“Joe, it sounds like you’ve been unhappy for months and hadn’t contemplated suicide before. Why are things so unbearable now?”

Key Points for Why Now?

Something unacceptable is about to happen.

Suicide or homicide threats have been made.

Ambivalence about living or dying, and both reasons for living and dying may be expressed.

Listen for both suicide risk and protective factors.

Are suicidal desire and intent present?

How is the person’s ability to cope being overwhelmed?

WITH WHAT?

What You Should Learn:

The means of suicide under consideration (if any)

Lethality of means being considered

Accessibility to the means selected (this requires a follow up question – where are the means?)

Whether more than one method is under consideration

Practice or rehearsal with the means selected

Sample Questions

“Have you thought about how you would kill yourself? If the person responds with a ‘yes,’ follow up with:- “Can you tell me how you’ve considered

ending your life?”- “How would you kill yourself?”- “Do you have a method in mind?”- “Have you practiced with the (means selected)?”

Redundant Planning?

Sample questions:

“Have you had any other thoughts of how you might kill yourself?”

“If the first method didn’t work what else might you try?”

Sample questions to determine the availability of means

“Do you have immediate access to (medications, a gun, a razor blade, etc.)?”

“Where is the gun (rope, razor, etc.)?”

“Where would you get the medications (gun, rope, razor, etc.)?”

Key Points for With What?

Rehearsal suggests suicide capability is present

Past self-injury (with any method)

Risk increases dramatically with access to means

Never suggest another method or means

Means selection is often influenced by culture, occupation, social contagion (modeling effect), and availability

Multiple methods under consideration = greater risk

WHERE AND WHEN?

What You Should Learn:A conditional suicide plan contingent on some unacceptable event, “If she leaves me I will kill myself.” “If they fire me, I die.” “If I’m arrested I will have to kill myself.”Possible location of a suicide attemptPlan for rescue or to avoid rescueDegree and details of lethal planningPossible anniversary phenomenaPotential for murder-suicide or suicide pact

Sample Questions

“Have thought about where you might try to kill yourself?”

“Have you decided when?”

“Is there something that might happen that would put your plan in motion?”

Key Points for When and Where?

Many suicide attempts are impulsive and little or no planning will be evidentGenerally, the more detailed the planning (intent) the greater the risk Specificity of time and place = greater riskDetermination of “anniversary phenomena” may open discussion of opportunities and a referral for help, e.g., grief counseling for a major lossEfforts to avoid rescue = greater riskResistance to disclosure of a suicide plan may indicate higher risk


What You Should LearnPast history of suicidal behaviors

Past history of intense suicidal ideation and/or planning

Method used in any suicide attempt(s)

Whether rescue was avoided

Timing and precipitants of past attempts


Social response to past attempt(s)

Treatment, if any, following a suicide attempt or period of severe ideation

Degree, if any, of medical injuries

Potential protective factors

Comparison of current method under consideration vs. prior method used

Sample questions“Pat, you’ve been struggling with a lot of different feelings lately and

you’re telling me you’ve been considering suicide. Have you ever had thoughts of suicide in the past?”

- If Pat responds “yes,” then ask:“When was that?

After learning when a previous episode of suicidality occurred, follow up with:

“Did you think about suicide seriously for two or more weeks?”“Did you attempt suicide at that time?”

Repeat the inquiry until you have the complete history

Key Points for When and With What?

Comprehensive history taking is strongly recommended

The more detail elicited the better

Suicide attempts while in treatment = greater risk and suggests extraordinary precautionary safety measures are indicated

Historical response to a past suicide attempt may provide insights into resolution of the current crisis

Attempt to avoid rescue? = greater risk

New method under consideration? = greater risk

WHO IS INVOLVED?

What You Should LearnRole of significant others Names of potentially helpful third partiesNames of potentially harmful third partiesNames of persons on whom the suicidal person feels he or she is a burden (a perceived, not necessarily real burden)Possible presence of a suicide pact or murder-suicide plan

Sample Questions

“Who are the people or the activities that are important to you?”

“Who else knows you are in this much pain?”

“Who is your main support during times like these?”

“Is there anyone who will be hurt if you take you own life?”

“If you feel like a burden on others, who are they?”

Key Points

Most suicidal crises involve at least two people, such as a couple in conflict

Suicide threats made to significant others without producing relief or change may suggest higher risk

Social isolation = greater risk

Feeling a burden to significant others = greater risk

Threats of violence toward others may be part of a planned suicide, or murder-suicide plan involving a conflicted relationship, students at school, or co-workers

WHY NOT NOW?

What You Should LearnOne or more protective factors (reasons for living)Spiritual or religious prohibitions against suicidePersonal or professional responsibilities to others (connectedness)Plans made for dependent others, such as, “My brother will raise my children.” Meaningfulness of life and purpose for livingResidual tasks to be completed before the attempt, such as making out a will

Sample Questions

“Give me some reasons why you may want to live?”“You’ve shared some reasons why you are considering suicide. What are some reasons that you should not kill yourself?”“Can you give me three reasons to go on living?”“Can you tell me about your core values and beliefs?”“Who are you close to? Who matters in your life”“What are your dreams for the future?”

Key Points

Few or no protective factors = greater risk

Serious isolation or rejection by others = greater risk

The offer of treatment, rest, hope, relief from suffering is a powerful protective factor

Marshalling protective factors lowers risk

Low risk does not equal zero risk

Persuading the Person to Get Help

KEY POINTS:Expressed anger at you may mean greater riskRefusal to accept help = greater riskAn abrupt or angry withdrawal from the interview may mean greater riskUnwillingness to remove the means of suicide = greater riskReassessment of risk may be indicated if help is refusedEmergency intervention, consultation and/or supervisory input should be readily available

I agree to continue to see my current provider and/or: Accept a referral to Community Mental Health

Accept a referral to

I also agree to the following: to remain clean and sober until crisis passes. to follow medical advice, including medication regime (if prescribed) to remove (or see to the removal of) the means of suicide. to not harm or kill self accidentally or on purpose. to call and talk to office, hotline, mental health provider or other responsible person in case of crisis. to accept responsibility for this safety plan.

My agreement to safety is:

Patient/family educated about access to (in)voluntary psychiatric hospitalization and community resources.

Patient/family accepts literature on suicide prevention and agrees to return for follow up.

Appropriate releases signed (if necessary).

Disposition and Signed Agreement or Check Here If Verbal Agreement OnlyI understand that my suicidal thoughts and feelings are the probable result of a current crisis, or of an untreated depressive illness, or of some other medical and/or psychological condition. Understanding this, and that treatment is available, I am willing to accept help. I agree to be safe and will not attempt or complete suicide while my provider and I pursue relief of my symptoms, problems and current distress. I have supplied my provider with names of relatives and/or friends whom he or she may contact about my safety plan.

Completed by: Date

Patient Signature: Date

Witnessed by:

Suicide risk is low to moderate

When:

- Few risk factors are present and several or many protective factors are present, and the person agrees to:

* Not use drugs or alcohol

* Seek help or accept a referral

* Remove the means of suicide

* Commit to a safety plan

Suicide risk is high

When: many risk factors are present and few or no protective factors are present, and the person:- Has been uncooperative- Has said little or nothing about his or her problems- Has been distant, evasive and aloof- Refuses to go along or agree to the referral and safety plan- Refuses to remove the mans of suicide

Low confidence note…

A progress note indicating a low confidence in the assessment means at least a moderate risk rating is warranted and reassessment is indicated in the near term (not more than 24 hours).

A second risk assessment opinion may also be indicated. Where confidence in the risk rating is low greater vigilance as well as ongoing or more frequent observation and monitoring is indicated.

Assessment confidence interval

What is low risk = ?

What is moderate risk = ?

What is high risk = ?

How confident are you in the assignment of these levels of risk? What if you’re wrong?

Low confidence note …

The person has been uncooperative and refused to collaborate in the assessment

Is suspected of being deceitful in answering questions

Has or may have psychotic symptoms, especially paranoia

Is or has been recently intoxicated

Low confidence note when the person…

Has a history of impulsivity

Refuses to sign releases to collect or confirm collateral information, such as medical records from other providers.

Is faced with an uncontrollable external event which may trigger a suicide attempt, such as the serving of divorce papers or a warrant to appear in court

And????

What else would cause you to have low confidence in your risk rating

Discussion….

Persuaded patient to accept help/treatment: Risk low, patient commits to safety plan. Risk moderate, commits to safety & referral plan.

Patient not persuaded to accept help/treatment: Risk high, initiate emergency room evaluation/(in)voluntary hospitalization procedure.

(NOTE ON CONFIDENCE INTERVAL HERE)

Referral. Patient agrees to remain with current provider and/or: Accepts a referral to Community Mental Health Accepts a referral to

P

R

Risk Management Plan. Patient verbally agrees: to remain clean and sober until crisis passes. to follow medical advice, including medication regime (if prescribed) to remove (or see to the removal of) the means of suicide. to not harm or kill self accidentally or on purpose. to call and talk to office, hotline, mental health provider or other responsible person in case of crisis. to accept responsibility for this safety plan. Quote patient's statement of agreement to safety:

Patient/family educated about access to (in)voluntary psychiatric hospitalization and community resources. Patient/family accepts literature on suicide prevention and agrees to return for follow up. Appropriate releases signed (if necessary).

Suicide Risk Management Inventory Paul Quinnett, Ph.D., and Kevin Bratcher, M.S., 1996

Completed by: Date White - chart copy, Pink - chart copy, Yellow - client/patient copy

T

QPRT

SEMANTICS ARE IMPORTANT

Poor safety agreement language

- “I guess I’ll be okay” (vague)

- “I’ll call somebody if things get bad.” (vague, lacks specificity. How will anyone know when things “get bad?” What is “bad” in this context? Who is “somebody?”)

Real people safety statements

“If things get this bad again, I’ll call my pastor. Honest, I will.”

“I won’t do it. I promise. I wouldn’t put Adam through that. I’ll call you back personally if I need to.”

“I can, and do, agree to a safety plan. I don’t want to die. I honor my word.”

KEY POINTS in Safety Agreements

Set specific times and expectations for crisis management action steps (work through safety plan checklist)

Recommitment to life; not a “no-suicide contract”

Clarity of language in a person’s recommitment to life and safety plan helps confirm risk is now lower

Hard copy directions, phone numbers, and how-to steps are helpful and key to avoiding claims of negligence

USE QUOTATIONS

For example, “I just couldn’t do that [suicide] to my family,” illustrates that, in this case, the family is a strong protective factor.

Likewise, the phrase, “I have a five-year-old boy and am pregnant right now,” indicates much lower suicide risk than, say, “I have no children and just had my first abortion.”

If the statement is not clear and unequivocal, try to help the person make the statement more clearly. The greater the clarity of this commitment, even over the phone to a stranger, the greater the likelihood the person will follow through with the recommended referral.

Role play practice sessions

Allow 25-30 minutes per role play

Complete sample QPRT as part of the practice session

Process each experience

All questions answered

When to use QPRTManaging Risk over Time

At admission

At discharge

At significant transitions during treatmentchange in risk factors (health, SA, loss, etc.)change in placement/caregivers

Documented in core clinical record

Please review your manual for windows of elevated risk….

THANK YOU!

Contact information

Free book from website

The Institute does not provide clinical consultation….