Suicide Risk: Comprehensive Assessment and Clinical Management

1. Suicide Risk: Comprehensive Assessment and Clinical Management David A. Brent, M.D. Western Psychiatric Institute and Clinic March 28, 2006

2. Objectives • Review descriptive epidemiology of suicidal ideation, attempts, and completion • Review risk factors for suicidality across the life span and diagnostic groups • Use risk factors for purposes of suicide risk assessment • Review management and treatment of patients who are suicidal or at high risk for suicide

3. Descriptive Epidemiology: Adolescents Suicidal ideation 20% Suicide attempts 1.3-3.8% males 1.5-10% females Risk for recurrent attempts 15-30%/year Risk for completed suicide 0.5-1.0%/year Increased risk of suicideamong attempters 10-60-fold increased

4. Descriptive Epidemiology of Suicidal Ideation and Behavior in Adults* Lifetime ideation 13.5% Ideation with a plan 3.9% Attempt 4.6% *Kessler et al., 1999

5. Hazard Functions of First Onset of Suicide Ideation, Plan, and Attempt (N=5877)* *Kessler et al., 1999

7. Suicide Rates by Age, 1982-2002 Data are from Center for Disease Control and Prevention

8. 2002 Suicide Rates by Race, Gender & Age Data from the Center for Disease Control and Prevention

9. Assessment of Suicidal Patients • Characteristics of suicidality • Current and lifetime psychopathology • Psychological characteristics • Family and environmental factors • Availability of lethal agents

10. Characteristics of Suicidality • Intent / current ideation • Lethality • Precipitant • Motivation • Environmental response

11. Suicidal Intent • “Wish to die”— based on self-report of observable behavior • Belief about intent • Preparatory behavior • Prevention of discovery • Communication of intent • Higher in completers than attempters • Predicts reattempt and completion

12. Assessment of Suicidal Ideation • Have you ever thought you would be better off dead? • Do you have thoughts of wanting to hurt yourself? (intensity and frequency) • Do you have a plan? • Do you intend to carry it out? • What things keep you from acting on your thoughts (Reasons for Living)? • What things would increase the likelihood of trying to hurt yourself?

13. Current Suicidal Ideation / Past Behavior • Intensity, now and worst ever • Frequency • Presence of active plan • Wish to carry out plan • Past history of attempt particularly within the past 6 months

14. Progression of Suicidality* Ideation to plan 34% Ideation to attempt 26% (90% in 1 yr) Plan to attempt 72% (60% in 1 yr) *Kessler et al., 1999

15. Lethality • Modestly associated with intent • But impulsive acts can be very lethal • Children can have high intent and low lethality • High lethality is associated with higher risk of completion • Availability of lethal agents important in younger, impulsive suicides • Ratio of attempts to completions drops with age

16. Non-Suicidal Self-Harm • Self-cutting, repetitive and stereotypical • To relieve distress/anger, pain, loneliness rather than to die • Often co-occurs with suicidal behavior

17. Precipitants • Abuse • Family discord • Romantic attachment disruption • Legal/disciplinary problems • Disruption of relationship very high risk for alcoholic suicides • Bereavement very important factor in geriatric suicidal behavior • Assess likelihood of recurrence

18. Motivation • Wish to die or permanently escape psychological painful situation(1/3 in younger individuals, but increases with age) • To influence others • Get attention • Express hostility • Induce guilt

19. Psychopathology • Over 80% of attempters and 90% of completers have at least one Axis I disorder • Most commonly mood disorder • High risk for bipolar disorder, particularly mixed state • Substance abuse • Cluster B disorders • Schizophrenia • Comorbidity, chronicity, severity

20. Age and Suicide • Suicide attempts and ideation more common in the young • Younger suicides more often involve Cluster B, substance abuse, impulsivity, aggression • Depression, schizophrenia-- suicide occurs relatively early in course • “Pure” depression and planned suicide more common in older adults • Alcoholics tend to commit suicide later in the course of the disorder

21. Prediction of Suicide Attempt in Community Samples* • Demographic: Age 15-24, female, <12 years old • Psychiatric: Mood disorder, psychoses, PTSD, substance abuse, ASP • Those with 3+ risk factors are 9.2% of population, but make up 55.1% of all attempters *Kessler et al., 1999

22. Psychological Characteristics • Hopelessness(dropout, poor treatment response, attempt) • Impulsivity and aggression (strong predictor of suicidal behavior, especially in presence of a mood disorder, familial component) - More important in suicide earlier in life • Social skills deficits(interpersonal problems) • Homosexuality, bisexuality(bullying, family rejection) • Inflexibility(in older suicides)

23. Family and Social Factors • Parental history of psychiatric illness and suicidal behavior • Abuse and neglect • Discord • Disruption of interpersonal relationships • Grief • Disconnection and “drifting”

26. Abuse and Neglect • Related to attempt and completed suicide • Sexual abuse prominent in early-onset disorders and attempts • Parental history of sexual abuse increases risk of attempt in offspring • Risk related to severity of abuse • Leads to cascade of mental health difficulties: early sexual activity, sexual assault, early pregnancy, marriage, divorce • Adversely affects course, adherence to treatment, response to treatment

27. Family and Social Protective Factors in Adolescents • Parent-child connection • High parental expectations • Parental supervision and availability • School connection • Religious affiliation • Non-deviant peer group

28. Protective Factors in Adults • Supportive family • Live with other people (spouse, child) • Children at home • Sense of connection and support • In older people, “pride in aging” • Sense of purpose

29. Availability of Lethal Agents • Case control and quasi-experimental study and guns • Detoxification of domestic gas • Blister packs for acetaminophen • SSRIs vs. TCAs

30. Guns in the Home & Suicide (OR) *95% CI excludes 1.0

31. Guns in the Home & Suicide (OR): Age † *95% CI excludes 1.0 † Kellermann et al., 1992

32. Rates of Suicide by Firearm During the Six Years After Purchase Among Persons Who Purchased Handguns inCalifornia in 1991 The horizontal line indicates the age- and sex-adjusted average annual rate of suicide by firearm in California in 1991 through 1996 (10.7 per 100,000 persons per year). Abstracted from Wintemute et al., New England Journal of Medicine, 341:1583-1589

33. Acetominophen (Paracetomol) and Suicide • Liver damage associated with > 25 tablets (OR= 4.5) • Those with access to bottle vs. blister pack 3 times more likely to take > 25 tablets • Only 20% thought a warning would deter them

34. Toxicity of Antidepressants: DAWN Kapur et al., 1992

35. End of Part I

36. Mnemonic for Assessing Suicide Risk AID ILL SAD DADS Distal Proximal

37. Proximal Risk Factors Agitation - Anxiety, agitation, EPS, insomnia Ideation - Active ideation with a plan Depression - Depression and decline, hopelessness Instability - Substance use, affective lability, mixed state or rapid cycling, brain injury Loss - Of relationship, work, health, or function Lethal agent- Availability of a gun

38. Distal Risk Factors Suicidal history - Personal or in family Aggression and impulsivity Difficult course - Poor treatment response, comorbid, severe Difficult patient - Non-adherent Abuse and trauma history Disconnection from support, work, relationships Substance or alcohol abuse

39. Suicide Among Inpatients* • Risk 137 / 100,000 admissions • Majority on weekend pass • In hospital - not on constant observation • Admitted for either planning or making an actual attempt • Recent bereavement • Chronic disorder, psychotic • Family history of suicide *Powell et al. 2000

40. Suicide in Psychiatric Inpatients* • 31% of inpatient suicides on unit, usually not on intense observation • Judged to be at low risk • Staffing, ward design, staff training, observation • Often homeless, SPMI, multiple admissions, previous non-adherence and self-harm *Meehan et al., 2006

41. Suicide within 3 Months of Discharge* • 32% occur within 2 weeks of discharge • Greatest number on first day post-discharge • 40% occurred before post-discharge contact with treatment in the community • Drugs and alcohol, non-adherence, previous self-harm, personality disorder • Prevention through improved treatment adherence and closer supervision (?) *Meehan et al., 2006

42. Suicide within 12 Months of Mental Health Service Contact* • Youngest and oldest suicide victims least likely to be engaged in treatment • In those under 25 - outreach to those with schizophrenia substance abuse, non-adherence, legal or relationship issues • In the elderly, recognition of depression, especially in context of bereavement and decline in physical health; suicide pacts most common in those with ill health in themselves, partner, living alone, low support *Hunt et al., 2006

43. Risk for Suicide in Mood Disorders (Bostwick, 2000) Hospitalized for suicidality 8.6% Hospitalized 4.0% Outpatient 2.2% Non-affectively ill 0.5% Tends to occur relatively early in the course of illness

44. Proximal Risk Factors for Suicide in Depression* • Agitation - Panic attacks, agitation, insomnia, poor concentration • Ideation - More specific (intent or planning) • Depression – Anhedonia; decline in health in elderly • Instability - Alcohol abuse • Loss, especially in elderly • Lethal agents *Fawcett et al., 1990

45. Distal Risk Factors for Suicide in Depression • Suicide history - Personal and family • Aggression - Impulsive aggression • Difficult course – Hopelessness • Difficult patient - BPD • Abuse and trauma • Disconnection • Substance abuse

46. Proximal Risk Factors for Suicide in Bipolar Disorder* • Agitation - Anxiety • Ideation - Ideation and recent attempt • Depression - More prominent • Instability - Mixed state, rapid cycling, substance abuse • Loss • Lethal agents *Hawton et.al., 2005a

47. Distal Risk Factors for Suicide in Bipolar Disorder* • Suicide history - Personal and family • Aggression and impulsivity - ? Role of lithium • Difficult course - More time in depressive state • Difficult patient – Non-compliant • Abuse and trauma • Disconnection • Substance abuse *Hawton et al., 2005a

48. Proximal Risk Factors for Suicide in Schizophrenia* • Agitation, EPS (Extra- pyramidal Symptoms) • Ideation • Depression and decline • Instability - Drug abuse • Loss - Recent loss, fear of mental isintegration • Lethal agent *Hawton et al., 2005b

49. Distal Risk Factors for Suicide in Schizophrenia* • Suicide history - Personal and family • Aggression and impulsivity • Difficult course • Difficult patient - Non-adherent • Abuse and trauma • Disconnection • Substance abuse *Hawton et al., 2005b

50. Proximal Risk Factors for Suicide in Alcoholics* • Agitation • Ideation - Ideation, threat, attempt • Depression and hopelessness • Instability - Recent heavy drinking, drug abuse • Loss - Recent interpersonal loss (within 6 weeks) • Lethal agents *Murphy, 1992; Conner et al., 2003, 2004