Suicide Risk Assessment and Documentation

1. Suicide Risk Assessment and Documentation Thad Q. Strom, Ph.D. Minneapolis VAMC

2. Acknowledgments • Thank you to Drs. Michael, Anestis, and Siegel for input and guidance on the following slides.

3. Objectives • Following this presentation, participants will be able to: • Discuss sociocultural factors that impact suicide assessment within the VA • Describe the concepts of the Interpersonal Psychological Theory of suicidal behavior • Describe risk factors for suicide • Successfully assess and document suicide risk level

4. Agenda • Brief discussion of interaction between VA related suicide, the media, politics and clinical care. • Overview of the Interpersonal-Psychological Theory of Suicidal Behavior • Review of a framework for determining suicide risk level • Briefly review documentation and VA suicide prevention initiatives

5. Suicide • 34,000 US deaths annually • 1 every 16 minutes • Approximately 93 per day • Approximately 20% are veterans (April 2010, DVA Fact Sheet) • 11th leading cause of death in US • 8th for males (19 per 100,000) • 16th for females (5 per 100,000) • 2nd leading cause of death in college students (3rd for age 10-24) • More common than death by homicide • 8.5-25 attempts for every death by suicide • Approximately 5,000,000 individuals in US have attempted CDC, 2007

6. Suicide • Sex differences • Men substantially more likely to die by suicide than women • White males over 65 years of age at greatest risk • Women three times more likely to attempt • 67% of male suicide deaths by firearms; 33% for women CDC, 2007

7. What do you assess for suicide risk? • What have you learned to assess for thus far in your career? • Why have you been told it is important to assess these things?

8. Interpersonal-Psychological Theory of Suicidal Behavior (IPTS) Joiner, 2005 Thwarted Belongingness Perceived Burdensomeness Lethal (or near lethal) Suicide Attempts Capability for Suicide • Perceived Burdensomeness • Makes no valuable contributions to world • Thwarted Belongingness • Has no meaningful connections to others • Acquired Capability for Suicide • Habituation to physiological pain and fear of death Desire for Suicide

9. IPTS – Empirical Support • Burdensomeness * Belongingness  • Suicidal Ideation (Joiner et al., 2009; Van Orden et al., 2008) • Acquired Capability for Suicide associated with… • Lifetime number of painful and provocative events (Van Orden et al., 2008) • Lifetime number of suicide attempts(Van Orden et al., 2008) • Range of combat experiences encountered by military personnel deployed in Operation Iraqi Freedom (Bryan et al., 2010) • PTSD re-experiencing symptoms (Bryan & Anestis, in press) • Higher in military samples than in civilian clinical and non-clinical samples(Bryan, Anestis, Morrow, & Joiner, 2010; Selby, Anestis, et al., 2010) • 3-way interaction of IPTS Components  • Clinician-rated suicide risk (Joiner et al., 2009) • Lifetime number of suicide attempts (Van Orden et al., 2008) Adapted from a slide from Michael Anestis

10. Determining Risk: A Framework • Seven domains of risk factors have been proposed: • Previous suicidal behavior • Nature of current suicidal symptoms • Precipitant stressors • General symptomatic presentation • Presence of hopelessness • Impulsivity and self-control • Other predispositions • Protective factors Joiner, Walker, Rudd, & Jobes, 1999

11. Previous Suicidal Behavior • The most important domain for risk assessment • Some evidence of important differences between: • Suicide ideators • Single attempters • Multiple attempters • For multiple attempters, the baseline risk will always be elevated. • History of attempts is always evaluated in conjunction with other risk domains.

12. Nature of Current Suicidal Symptoms • Divided into two factors: • Resolved plans and preparation • Ex: Feeling competent and courageous to make attempt, availability of means and opportunity, duration and intensity of ideation. • Suicidal desire and ideation • Ex: Reasons for living, wish to die, frequency of SI, talk of death and/or suicide. • While frequency of SI is noteworthy, intensity and duration of SI is a more pernicious indicator.

13. Precipitant Stressors • Important to assess for recent life stressors • Particularly those involving interpersonal loss and disruption • Ex: relationship disruption, legal troubles, physical/emotional abuse • Attempt history tends to affect the duration of suicidal symptoms following crisis. • Even non-attempters may develop SI in the face of life crises, but the duration of this crisis is likely to be shorter.

14. Risk Factors (cont’d) • General Symptomatic Presentation Including Hopelessness • Review the presence and severity of Axis I and Axis II symptomatology. • Perhaps the most commonly reviewed through grad school training • Impulsivity and Self-Control • Impulsivity tends to be a trait factor that is present throughout a person’s life • Other Pre-disposing factors • Chaotic childhood, sexual/physical abuse

15. Protective Factors • Social support • Self-perceived quality of social support • Self- control and problem-solving ability • These do not negate serious risk factors (e.g., multiple attempts) but may help determine level between categories.

16. Determining Risk: A Continuum • Presence of multiple attempts in conjunction with other risk factors determines severity. • Severity Ratings: • Non-existent • No identifiable suicidal symptoms, no past history, and no or few other risk factors • Mild • Multiple attempter with no other risk factors, OR • A nonmultiple attempter with SI of limited intensity and duration, and • No or mild planning/resolution, and • No or few other risk factors Joiner, Walker, Rudd, & Jobes, 1999

17. Determining Risk: A Continuum • Moderate • A multiple attempter with any other notable finding, OR • A non-multiple attempter with severe to moderate preparation and resolution • Severe • Multiple attempter with any two or more notable findings • Non-multiple attempters with significant preparation/plans and at least one other risk factor • Extreme

18. Graphic Representation Multiple Attempter? Resolved Plans & Preparation? Yes No Yes No Any other significant risk factor = AT LEAST Moderate Risk Any other significant risk factor = AT LEAST Moderate Risk Suicidal Desire & Ideation? No Yes Two or more other significant risk factor = AT LEAST Moderate Risk Joiner, Walker, Rudd, & Jobes, 1999

19. Documentation • Progress notes • No-show/cancellation notes • Risk Flags • Suicide behavior reports • Safety Plans • Standard disclaimer: If the risk assessment or outreach is not documented, then it is considered to never have happened!

20. No-shows and Cancellations • Consider outreach on a continuum: • Do nothing • Send a letter • (Try to) call the veteran • (Try to) call individuals for whom there is a signed release of information • Contact the sheriff’s department to arrange for a welfare check • Consider the potential effects of outreach attempts on the treatment and the therapeutic relationship • Generally better to err on the side of higher-level outreach

21. Suicide Behavior Report • Necessary documentation when an attempt has been made, or there is a clinically relevant increase in risk for someone who has had a suicide behavior report noted previously. • Reviewed and tracked by suicide prevention coordinator • May lead to a suicide behavior flag in the veteran’s chart.

22. Suicide and the Media

23. VA Campaigns to Reduce Suicide • Suicide Prevention Coordinators • http://www.mentalhealth.va.gov/suicide_prevention/ • Suicide Risk Flag in CPRS

24. Our Local Facility • Let’s discuss some risk management procedures locally.

25. Links • Military Suicide Research Consortium • https://msrc.fsu.edu/ • Psychotherapy Brown Bag • www.psychoterapybrownbag.com • National Institute of Mental Health • www.nimh.nih.gov • Substance Abuse and Mental Health Services Administration (SAMHSA) • www.samhsa.gov • National suicide prevention number: 1-800-273-TALK • Suicide Prevention Resource Center • www.sprc.org