Basic Suicide Risk Assessment

1. Basic Suicide Risk Assessment Stacey Moody McHenry

2. Suicidal thoughts and behaviors are common in people diagnosed with the following disorders: • Major depressive disorder, bipolar disorder, schizophrenia, PTSD, anxiety, chemical dependency and personality disorders (like borderline personality disorder and antisocial personality disorder). • In other words, the presence of a psychiatric diagnosis increases the risk for suicide especially when substance abuse is co-occurring with another mental illness • Sounds like most of the population we serve, doesn’t it?

3. Suicidal Thoughts and Behaviors May Be More Common Than You Think • 13.5% of Americans (in the general population) reported a history of suicidal ideation at some point in their lifetime • 3.9% reported making some kind of plan • 4.6% reported having an attempt • Of attempters, 50% reported making a serious attempt • 90% of suicide attempters do not go on to commit suicide • 16% of high school students who were asked reported seriously considering suicide in the past year • 13% of those high school students reported having made a suicidal plan • 8.4% of those high school students report having made an attempt during the prior twelve months (CDC, YRBS 2005) • THESE NUMBERS ARE EVEN HIGHER WHEN A PSYCHIATRIC DISORDER IS PRESENT

4. With our population, you may be tempted to think that “he or she just says that” but remember there is a continuum from thoughts to attempts • 34% of people who think about suicide report transition from serious thoughts to making a plan • 72% of planners move from making a plan to an attempt • Of attempters, 60% of planned attempts occur within the first year of ideation onset and 90% of unplanned or impulsive attempts occur within that first year • 60% of suicides succeed on their first try (Thomas Gutheil, MD) • THIS IS WHY WE WANT TO ENCOURAGE PEOPLE TO TALK TO US RATHER THAN IGNORE OR PUNISH THIS TYPE OF COMMUNICATION

5. The Statistics on People Who Commit Suicide (according to Thomas Guthiel, MD, who does forensic investigations after the fact in connection with litigation: In other words, this is what the experts to the malpractice lawyers say after the fact) • 60 % never saw a clinician • Only 3% were on the appropriate medications!!! • Only 3% got ECT—He considers ECT an “under-utilized life saving method” • 80% were seen by their general practitioner in the past year

6. Functions of Self Harm Not all people who think about suicide want to die. People think about self harm and engage in self harm for a variety of reasons: • Suicidal thoughts can be adaptive and act as a safety valve (blowing off steam like the top on a tea kettle)like having a back up plan if things don’t work out • SIB (like cutting, head banging or swallowing)regulates intense emotions or manages auditory hallucinations temporarily • Can be an impulsive step people take when the control centers in the brain are impaired like in cases of substance use, TBI or chronic encephalopathy • Can be associated with irrational thoughts or command hallucinations such as in psychosis either with or without depression • Can occur during active substance use or as a result of withdrawal • Self harm can serve to communicate or solve other problems like chronic emotional or physical pain • Engaging in self harm can serve as a distraction or a means of avoiding something else (like trauma symptoms) • “Manipulative suicide” according to Sifneos, the goal is not to die but to “live better”

7. How do we tell the difference? • By evaluating the research, including risk factors and possible protective factors regarding suicide • By conducting a thorough and thoughtful assessment • No one risk factor has been proven to increase or decrease the risk for suicide; however, the risk of suicide increases with an increase in the number of risk factors present

8. Look for the Early Warning Signs • A recent review of the literature from all over the world identified a number of signs that empirically have been related to the acute onset of suicidal behaviors (within hours to days). • THESE THREE FACTORS SHOULD ALERT US TO THE PRESENSE OF ACUTE RISK FOR THE EXPRESSION OF SUICIDAL BEHAVIOR AND REQUIRE IMMEDIATE ATTENTION, EVALUATION, REFERRAL AND CONSIDERATION OF HOSPITALIZATION: • Threatening to hurt or kill oneself • Looking for ways to hurt or kill self (access to pills or weapons) • Talking or writing about death, dying or suicide

9. Other warning signs require an evaluation and that a plan be put in place to ensure the person’s safety • Hopelessness • Rage, anger, seeking revenge • Key affect according to Gutheil is aloneness, self-hatred, rage or shame • Recklessness or engaging in behaviors, seemingly without thinking • Feeling trapped, no way out • Increasing substance use • Withdrawal from family, friends, society • Anxiety, agitation, unable to sleep or sleeping all of the time • Dramatic change in mood • No reason for living, no sense of purpose in life • Divesting self of responsibility (children, pets, elderly) or possessions • Settling affairs (making a will, paying bills) • Saying goodbye to loved ones

10. SAHMSA recommends the following five steps being considered in every suicide assessment CALLED “SAFE-T” (for suicide assessment five-step evaluation and triage) • 1-Identify Risk Factors • 2-Identify Protective Factors • 3-Conduct Suicide Inquiry • 4-Determine the risk level and intervention to address and reduce risk • 5-Document-the assessment of risk, rationale, intervention and follow-up

11. Factors That Increase the Risk for Suicide, Suicidal Gestures and Thoughts • Recent Life Events or Losses (ex-employment, career, financial, housing, marital, relationship, health) • Chronic or Long Term Problems (like relationship difficulties, unemployment, legal problems, sexuality, bullying) • Acute or extreme psychological distress (humiliation, despair, guilt and shame) • Certain physical disorders (diseases of the central nervous system like epilepsy, tumors, Huntington’s Chorea, Alzheimer’s, MS, and spinal chord injuries)(certain cancers, autoimmune diseases, renal disease and HIV/AIDS. • Traumatic Brain Injuries (higher rate of suicidal ideation, attempts and completions than the general population and the sequelae of TBI like depression, personality changes, loss of functioning, anxiety, psychosis, impaired attention and problem solving, and IMPULSIVITY can lead to a life-long increased risk requiring constant monitoring • Chronic Pain • AGE (all ages but remember that teens are at high risk, and the elderly are at high risk) • History of attempts or person close to you attempting or completing a suicide • Current ideation, plans, access to means

12. More factors that increase risk for suicide, suicidal gestures and thoughts • Substance use-(lifetime risk in alcoholics is 2-3X the general population, alcoholics account for 15-25% of suicides) • Current or previous psychiatric diagnosis-(according to the Schizophrenia Bulletin, the number one cause of death among individuals with schizophrenia is suicide) • Impulsivity or poor self control • Hopelessness-assess presence, duration and severity • Recent discharge from inpatient facility • History of abuse/trauma • Recent diagnosis with a medical or psychiatric condition • Demographics (unmarried, white, male, living alone) • Sexual Orientation

13. Protective factors that may decrease the risk • Having a strong social support network • Spiritual beliefs • A sense of responsibility to family, children or pets • Pregnancy • Life satisfaction • Reality testing ability • Positive coping skills • Positive problem solving skills • Positive therapeutic relationship • Reasons to live. Future orientation. • Do not assume that any one or more of these is enough to mitigate risk. Talk to the person and determine how he or she is looking at the situation.

14. Won’t talking about suicide and giving a person a lot of attention around suicidal thinking reinforce a person to think and talk about it more often? • Myth: Asking about suicide will put the idea in person’s head. • Myth: People who talk about it don’t do it. • Myth: If someone really wants to commit suicide there is nothing you can do about it. • Myth: A person who has kids and supportive family, has vacation plans, has future plans. . . Would not kill themselves. • Myth: You can rely on a contract for safety to keep a person safe. • Myth: Most people who talk about suicide or make gestures are being manipulative and trying to get attention. • Fact: Asking does not cause suicide anymore than asking about chest pain causes heart disease. Ideation is the symptom not the cause. • Fact: Most people who suicide communicated some intent. • Fact: Most suicidal ideas are associated with underlying treatable conditions. The acute risk is often time limited. Help the person stay safe while addressing the concerns. • Fact: Suicidal thinking can take over rational thought. • Fact: “No suicide” contracts have been shown to be ineffective in managing risk. The reports of their effectiveness is probably better explained by the strength of the alliance with the person who took the time to talk and work out a plan for support. • Fact: Multiple prior attempts increase the likelihood of successful suicide. They may serve to desensitize the person to the actual attempt and teach a person how to employ more lethal strategies. Besides-What does a person have to do to get your attention? The goal is to help the person understand their behavior and find healthier and safer ways to ask for help.

15. Now that I know that I should acknowledge unusual statements, behaviors, warnings or threats, what should I say? • Start by empathically validating the person’s pain- Something like, “I appreciate how hard this must be for you. Some people who experience ____ have told me they have thoughts about hurting themselves, I wonder if this has ever happened to you?” • Find out if the person is feeling hopeless about the future- Hopelessness is a strong predictor of suicidal ideation and self harm behaviors. Hopelessness is also associated with feelings of helplessness, worthlessness and despair. You might find out about hopelessness by asking the person what options they think exist for handling the problem or concern. • Ask whether the person has any history of trying to harm themselves. 16% of people who attempt suicide try again within one year and 21% try again within 1-4 years. Most repeat attempters will use more lethal means. Approximately 2% of attempters die by suicide within one year. 8-10% of attempters will eventually die by suicide. • Learn more about the timing of suicidal ideation. It is important to know what triggers the thoughts, whether the thoughts are continuous or intermittent, how much time is spent during the day thinking about suicide, and how easy or hard it is to ignore the thoughts. Knowing what makes the thoughts better or worse may help you formulate your safety plan. • Ask about a plan. The presence of a plan indicates that the person has some intent to die and has begun preparing. It is important to find out how lethal the plan is, and how likely or unlikely the person could be saved, discovered, rescued. • Find out if the person has begun to enact or rehearsed the plan. Find out if the person has the means to carry out the plan. Have they begun to hoard medication, purchased a firearm or rope, written a note, started to settle their affairs?

16. Allow Me to Emphasize • Fire arms account for 55-60% of suicides • You need to ask about weapons of any kind in the home, or whether person has access to weapons, and order that weapons be removed • You need to follow up with family members who may be in as much denial as the person about the seriousness of the situation • According to Gutheil, “if you haven’t asked about guns, you don’t know how to do a suicide assessment.” • Document the conversation!!!

17. What if the person denies having suicidal ideation and plans? • Many people will deny suicidal thoughts and behaviors because there is a stigma against people with mental illness, they are ashamed or they are afraid that people will over-react and punish them for just having thoughts. • Other people will feel relieved when someone is knowledgeable about managing suicidal thoughts and triggers and is able to talk with them in a non-judgmental way. • Even if the person denies suicidal thoughts and plans, rely on your own observations about whether the person is at baseline, is guarded or is withdrawn, irrational, paranoid, depressed, agitated, highly anxious, ashamed, angry, rageful, or vengeful. Don’t discount your observations. At least discuss your concerns with a supervisor or colleague. • Guthiel talks about the “alliance threat.” When a person has decided to commit suicide, the treater is an enemy, not an ally, thus information may be withheld.” You “cannot always rely on the alliance. Our patients are cut off from their own suicidal feelings. When the therapist reaches out, they connect with the outer shell.” “Use your brain, not your empathy.” • Guthiel’s advice, “you are the kind of person who will get a second opinion. Get a peer involved. What would a reasonable practitioner do? Document your rationale. You may be stupid but not negligent.” A five minute consultation by telephone with a doctor or nurse, leave out the names. . . [document] case reviewed anonymously with doctor or nurse who concurs with plan.” Is most underutilized.”

18. What can be done when a person is in imminent risk of self harm? • If the person is about to engage in self harm call 911. • Remove lethal means like guns, knives, pills, ropes, drugs and alcohol. • Seek the help of someone more experienced if you are uncertain and you are able to do this without jeopardizing the immediate safety of the person. • Medications-The only two medications that have been shown to lower suicidal risk are lithium (usually prescribed for bipolar disorder) and clozapine (usually prescribed for psychotic disorders like schizophrenia). These medications do not reach the therapeutic dosage immediately. There are other medications that may be used to treat symptoms like insomnia, anxiety and agitation. Because serotonin levels have been related to aggression and impulsivity, SSRI’s are recommended for depression when suicidal ideation is present. Remember-there is research demonstrating that some medications prescribed for depression actually increase suicidal thinking in some populations (particularly people under the age of 25). • Hospitalization-Sometimes the only way to keep a person safe in the short term is to place them in a setting that is accustomed to managing acute risk • Increase level of supervision and support. • Referral for follow –up assessment and treatment of underlying condition.

19. The Final Step: Communicate and Document • After doing all of the hard work to identify the risks, protective factors, the content, duration, and severity of the person’s thoughts and plans, the correct level of intervention, formulating and implementing a safety plan….. • Make sure you communicate what you know to your fellow team members! • Make sure you document your assessment, rationale, interventions and any required follow-up!