Transcript No Slide Title

Suicide Risk: Comprehensive Assessment
and Clinical Management
David A. Brent, M.D.
Western Psychiatric Institute and Clinic
March 28, 2006
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
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 suicide
among attempters
10-60-fold increased
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
Hazard Functions of First Onset of Suicide
Ideation, Plan, and Attempt (N=5877)*
*Kessler et al., 1999
Suicide Rates by Age, 1982-2002
Deaths per 100,000
30
15-24 yr
25-34 yr
35-44 yr
45-64 yr
65 -74
75-84
85+
25
20
15
10
1982
1987
1992
1997
Year of Death
Data are from Center for Disease Control and Prevention
2002
2002 Suicide Rates by Race, Gender & Age
60
Deaths per 100,000
50
White Males
White-Females
Black Males
Black Females
Other Males
Other Females
40
30
20
10
0
15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84
yrs
yrs
yrs
yrs
yrs
yrs
yrs
yrs
Age
Data from the Center for Disease Control and Prevention
85 +
yrs
Assessment of Suicidal Patients
•
•
•
•
•
Characteristics of suicidality
Current and lifetime psychopathology
Psychological characteristics
Family and environmental factors
Availability of lethal agents
Characteristics of Suicidality
•
•
•
•
•
Intent / current ideation
Lethality
Precipitant
Motivation
Environmental response
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
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?
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
Progression of Suicidality*
Ideation to plan
Ideation to attempt
Plan to attempt
*Kessler et al., 1999
34%
26% (90% in 1 yr)
72% (60% in 1 yr)
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
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
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
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
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
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
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
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)
Family and Social Factors
• Parental history of psychiatric illness and
suicidal behavior
•
•
•
•
•
Abuse and neglect
Discord
Disruption of interpersonal relationships
Grief
Disconnection and “drifting”
Cumulative Proportion of Suicide Attempt Among
Offspring of Attempters vs Non-Attempters
C um ulative proportion
Proband Status:
Attempter
Non-Attempter
0.5
0.4
0.3
0.2
0.1
0
0
5
10
15
20
25
30
35
40
Age of first-onset of suicide attempt (years)
Generalized Savage: 2 = 7.89, p = .005
OR = 6.2, 97.5% CI, 1.2 to 33.4
Figure 1.
Cumulative Proportion of Suicide Attempt Among Offspring of
Concordant Attempters vs. Non-concordant Attempters vs. Non-attempters
Cumulative proportion
0.5
0.4
0.3
0.2
0.1
0.0
0
10
Concordant
Non-concordant
Non-attempters
20
Age (years)
30
40
2
Generalized Wilcoxon x : 10.1, df=2, p = .007
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
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
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
Availability of Lethal Agents
• Case control and quasi-experimental
study and guns
• Detoxification of domestic gas
• Blister packs for acetaminophen
• SSRIs vs. TCAs
Guns in the Home & Suicide (OR)
Any
Gun
Long
Gun
Hand
Gun
Loaded
Gun
Brent et al., 1993
4.4*
-
9.5*
-
Kellermann et al., 1992
4.8*
3.0*
5.8*
9.2*
Beautrais et al., 1992
1.4
-
-
-
Bailey et al., 1997
4.6*
-
-
-
Shah et al., 2000
3.3*
-
-
-
*95% CI excludes 1.0
Guns in the Home & Suicide (OR): Age †
Age (Years)
OR
0-24
10.4*
25-40
7.2*
41-60
4.0*
≥ 61
6.6*
*95% CI excludes 1.0
† Kellermann et al., 1992
Suicides by Firearm
(no./100,000 person-years)
Rates of Suicide by Firearm During the Six Years
After Purchase Among Persons Who Purchased
Handguns in California in 1991
100
75
50
25
0
1
2
3
4
5
6
Years
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
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
Toxicity of Antidepressants: DAWN
Drug
Odds of
Attempt
Odds of
Suicide
Desipramine
1.51
16.66
8.5
Amitryptiline
1.07
4.79
2.5
Imipramine
1.21
4.66
2.5
Fluoxetine
1.00
1.00
1.0
Kapur et al., 1992
Risk of Death
in OD
End of Part I
Mnemonic for Assessing
Suicide Risk
AID
ILL
Proximal
SAD
DADS
Distal
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
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
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
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
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
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
Risk for Suicide in Mood Disorders
(Bostwick, 2000)
Hospitalized for suicidality
Hospitalized
Outpatient
Non-affectively ill
8.6%
4.0%
2.2%
0.5%
Tends to occur relatively early in the course of illness
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
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
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
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
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
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
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
Distal Risk Factors for Suicide in
Alcoholics*
• Suicide history - Personal and family
• Aggression - Impulsive aggression
• Difficult disorder - Early onset, comorbid, chronic course
•
•
•
•
Difficult patient - Non-adherent
Abuse and trauma
Disconnection
Substance abuse (especially polysubstance abuse)
*Murphy, 1992; Conner et al., 2003, 2004
Proximal Risk Factors for Suicide in
Eating Disorders
• Agitation – Obsessive concern about weight
• Ideation
• Depression and hopelessness
• Instability - Drug and alcohol abuse, mood lability
• Loss
• Lethal agent
Distal Risk Factors for Suicide in Eating
Disorder Patients
• Suicide - Personal history
• Aggression and impulsivity - Cluster B personality
• Difficult course - Poor treatment response, binging / purging, high
obsessionality, lower BMI, longer course
•
•
•
•
Difficult patient
Abuse and trauma
Disconnection
Substance abuse
Proximal Risk Factors for Geriatric
Suicide
• Agitation - Insomnia, anxiety, traumatic grief
• Ideation
• Depression, decline and hopelessness
• Instability
• Loss of relationship; health, function (in self or spouse)
• Lethal agent
Distal Risk Factors for Geriatric
Suicide
• Suicidality - Personal and family history
• Aggression - Not so prominent
• Difficult course
•
•
•
•
Difficult patient
Abuse and trauma
Disconnection from supports
Substance abuse
Why Target Depression?
• 80% of attempters and 60% of completers are
depressed
• Depression increases the risk for suicidal
behavior 10- to 50-fold
• Quality improvement studies also suggest
that improved treatment of depression
reduces suicidality risk (Asarnow et al., 2005;
Wells et al., 2001; Brown et al., 2001)
• Pharmacoepidemiological studies show
reduction in suicide with SSRI use
Treatment of Depression Reduces
Suicidal Risk
• Gotland study – Improvement in GPs ability
to treat depression resulted in decreased
suicide rate
• PROSPECT – Collaborative care for
depressed suicidal elders was more effective
than TAU for reducing suicidality
• Pharmaco-epidemiology studies – Increase
in SSRI prescription related to decline in
suicide, particularly in 15-24 year-olds
Gotland Study: Suicide Rates
(per 100,000)
30
Intervention
25
20
Sweden
Gotland
15
10
5
0
1982
*p<0.01
1983
1984
1985
Treatment of Depression May Not
Reduce Suicidal Risk
• The most suicidal individuals are
excluded from clinical trials of
depression
• Suicidality is associated with other
factors that also predict treatment
non-response of depression
(chronicity, severity, comorbidity,
personality disorder)
Khan et al., 2000: FDA Database
(n=19,639)
3.5
3
2.5
Suicide
2
1.5
Attempted
Suicide
1
0.5
0
Drug
Comparator
Placebo
Storosum et al., 2001: Dutch Studies,
1983-1997
Short Term
0.7
Suicide Rate %
Suicide Rate %0
0.4
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
Long Term
0.6
0.5
0.4
Suicide
0.3
Attempted
Suicide
0.2
0.1
Drug
0
Placebo
Drug
Placebo
Changes in Mood and Suicidality Not
Always Closely Related
• Suicidal behavior is multifactoral
• Studies of CBT, IPT, antidepressants differentially
decrease depression, but not suicidal ideation, attempts
(Brent, 1997; Lerner, 1990; Mufson, 1999; Khan et al.,
2000; Storosum et al., 2001)
• Studies that decrease suicidal ideation / attempts do not
affect mood (Linehan, 1991; Harrington, 1998; Wood,
2001)
• SSRIs may increase suicidal risk
End of Part II
SSRIs and Suicidality: A Summary of
the FDA Findings
• Rate of “suicidality” increased 1.78-fold
• On average drug vs. placebo, 4% vs. 2%
• Mostly new or worsened ideation, few attempts, no
completions – question clinical significance
• Early in treatment
• Most common in trials that also showed increase in
hostility
• No difference in ideation on standard measures
• More pronounced in non-depressed (e.g., anxious,
OCD) subjects
Pittsburgh Meta-Analysis: Efficacy and Suicidality in Pediatric
Clinical Trials for MDD, OCD and ANX*
Indication
N
Response %
Drug Placebo
NNT
Suicidality
Drug
Placebo
NNH
MDD
2,750
59.5
47.9
9
45/1,708
21/1,433
125
OCD
705
51.5
32.2
6
4/362
1/339
200
ANX
1,143
68.9
38.8
3
6/573
1/582
143
*Bridge et al., in preparation
Suicidality and Antidepressants
Drug %
Placebo %
Pooled
Risk Difference*
(95% CI)
Pooled
Relative Risk*
(95% CI)
MDD
2.6
1.5
0.8%
(-0.2%-1.8%)
1.7
(0.97-2.8)
OCD
1.1
0.3
0.5%
(-0.1%-2.2%)
1.8
(0.4-8.5)
ANX
0.4
0.2
0.7%
(-0.0%-1.8%)
3.1
(0.6-16.8)
*Using random effects models
Rates of Suicide Attempts During the 3 Months Before and
the 6 Months After Initial Antidepressant Prescriptiona
aBars
indicate 95% confidence intervals
Simon et al., 2006
Treatment Studies of Adult Suicide Attempters
Type of Treatment
Comparison
Odds of Repetition
(95% CI)
Problem-solving therapy
Usual aftercare
0.73(0.45-1.18)
Intensive aftercare
Usual aftercare
0.83(0.61-1.14)
Emergency care
Usual aftercare
0.45(0.19-1.07)
Usual care
0.24(0.06-0.93)
Antidepressant
Placebo
1.19(0.53-2.67)
Flupenthixol
Placebo
0.09(0.02-0.50)
Dialectical behavior
therapy
Hawton et al., 1998
Dialectical Behavior Therapy (DBT)
• Linehan et al., 1991: DBT vs. TAU: 64% vs.
96%
• 1 year follow-up: DBT vs. TAU: 26% vs. 60%
(parasuicide episodes), by 2 years, differences
were gone
• Van der Bosch 2002: lower DSH in BPD with
SA
• Bohus et al., 2004: lower DSH: 38% vs. 69%
CBT for Prevention of Recurrent
Attempts
•
•
•
•
•
Chain analysis of attempt
Focus on cognitions leading to attempt
Safety plan
Case management
Two-fold reduction in re-attempt
Brown et al., 2005
Survival Curves of Time to Repeat Suicide
Attempt*
*Brown, G. K. et al. JAMA 2005;294:563-570.
Treatment Studies with
Suicidal Youth
Harrington et al. (1998) – Home-based family
intervention no better than TAU for adolescent
overdose attempts. In non-depressed group family
treatment reduced ideation
Wood et al (2001) – 6-session group treatment
>TAU for reducing single (OR=.6) and recurrent
attempts (OR=.16), anger, and conduct disorder,
but not depression. More of experimental
treatment better, more of TAU worse.
Effects of Long-Term Contact
on Suicide*
• 843 inpatients hospitalized for depression
or suicidality and refused ongoing care
• Randomized to contact or no contact
• Contact letter with 24 contact, over 5 years
• Significant in suicide rate difference at 2
years = 1.7-% vs. 3.6%
*Motto & Bostrom, 2001
Aftercare: Postcards from the Edge*
• 772 patients who made overdose, ≥ 16
years of age
• Received postcards (up to 8) and standard
treatment vs. standard treatment alone
• Proportion of repetition in experimental
group is lower (15.1% vs. 17%)
• RR=0.55
• Reduction in bed-days=110
*Carter et al., 2005
Carter et al., 2005
Pharmacologic Targeting of Impulsive
Aggression and/or Suicidal Behavior
• Lithium – decreases aggression, quasiexperimental findings, decreases suicide rate
in adults
• Neuroleptics – Risperidone decreases
aggression in children, RCT clozapine >
olanzapine for suicidal schizophrenics
• SSRIs – decrease in impulsive aggression in
one study, did not decrease recurrent suicide
attempts in two studies
Forest Plot Showing Meta-Analysis of Suicides Plus
Deliberate Self-Harm in Randomized Trials Comparing
Lithium with Placebo or Active Comparators
Cipriani et al., 2005
Lithium and Odds of Suicidal Behavior
OR
Pt. Yrs.
Contrast
Bipolar Disorder*
20.7
44,584
Li vs. No
All Mood Disorders*
11.0
64,233
Li vs. No
Unipolar Depression*
19.5
4,740
Li vs. No
Unipolar Depression†
4.2
Li vs. No
Bipolar Disorder‡
2.7/1.7 60,060
DV vs. Li
CM vs. Li
*Baldessarini, 2003
†Coppen,
2000
‡Goodwin, 2003
Direct Targeting of Suicidal Behavior:
Clozapine*
• 980 schizophrenic or schizoaffective patients
• Randomized to clozapine or olanzapine
• Suicide attempt rate lower in those treated
with clozapine (34% vs. 55%, p=0.03)
*Meltzer et al., 2003
Montgomery et al., 1994: Prevention of
Recurrent Suicide Attempts in Patients with
Recurrent Brief Depression
N
Suicide Attempt (%)
Fluoxetine
Placebo
54
53
33.3
34
Verkes et al. (1998) Paroxetine
for Recurrent Attempt
50
45
40
35
30
25
20
15
10
5
0
*
Overall
*p<.05
<5
Attempts
Paroxetine
Placebo
*
-B
+B
TASA (Treatment of Adolescent Suicide
Attempters) CBT
•
•
•
•
•
Safety plan
Case management
Chain analysis of attempt
Focus on cognitions leading to attempt
Two-fold reduction in re-attempt in Brown
et al. (2005)
• Now being tested in multi-site study of
adolescent attempters funded by NIMH
Chain Analysis of Suicide Attempt
•
•
•
•
•
•
Precipitant
Motivation
Negative affect
Hopelessness
Emotion regulation
Environmental response
Management of “External Factors” in
Treatment of Attempters
Family
Availability of
Lethal Agents
Discord
School
Problems
Social Skills
Training
Attempt
Interpersonal
Difficulties
Restrict
Access to
Means
Case Management
Adjust Expectation
Family Therapy , Education
Treatment of Parents
Management of “Internal Factors” in
Treatment of Attempters
Hopelessness
Negative Affect and
other Disorders
Emotional
Lability
Impulsivity
Attempt
Problem-solving
Positive Health
Habits
Cognitive
Restructuring
Emotion
Regulation
Distress, Tolerance,
Treatment Disorder
In setting treatment priorities,
ask (collaboratively):
• What will yield the greatest risk
reduction for the least effort?
• Is it something that can be changed?
• Does the patient want to / have the
capability to change this factor?
Relapse Prevention Session
• Imagine situation that led to
attempt
• Role play how would cope now
• Identify skills and resources
necessary to stay well
Treatment Guidelines
•
•
•
•
•
•
Establish safety plan
Increase likelihood of adherence
Determine appropriate level/intensity of care
Increase hopefulness about treatment
Conduct chain analysis of the attempt
Target most relevant individual and environment
factors to the suicide attempt
• Increase protective factors (family connection)
• Coping plan, hope kit
Safety Plan
• Will try to implement coping plan
• Promises family and clinician not to engage in
suicidal behavior OR
• Will contact clinician/family/responsible adult
if suicidal thoughts reoccur
• Need 24-hour availability or back-up
• Review precipitants, develop truce and
conduct brief training in emotional regulation
• Secure lethal agents
Secure Lethal Agents
•
•
•
•
Find out motivation for gun ownership
Find out who owns the gun
Negotiate most secure situation possible
Parental regulation of medication
Hopelessness
• Address hopelessness about treatment first
• On a scale of 1-10, how hopeful are you that
we can help you? What would
increase/decrease it?
• Establish concrete, realistic, achievable goals
• Reasons for Living
• Predict “bumps in the road” to prevent undue
discouragement
Education
• Educate parents and families about depression
as a chronic and recurrent illness
• Depression is nobody’s fault
• Help set reasonable expectations regarding
chores, school, work
• Often family members are worried and want
information and reassurance from a withdrawn
and secretive patient
• Goal to teach family and patient how to monitor
for treatment response, side effects, and longterm course
Recognize Intercorrelation of
Health Risk Behaviors
• Unprotected sex
• Alcohol, drug, tobacco
use
• Weapon-carrying
• Binge eating and obesity
• Bullying/being bullied
Increase Protective Factors
• Improve family-patient connection,
supervision, expectations
• Improve school connection (when
relevant)
• Choice of friends and romantic
attachments / marriage
• Connection to social groups and
institutions
Education and Anticipation: Relapse
and Recurrence Prevention
• Sleep hygiene
• Avoidance of tobacco, alcohol
and drugs
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•
•
•
Pleasurable activities
Self-talk and practice of skills
Exercise
Detection of relapse
Summary
• Provide a framework for assessing suicidal
risk, examining proximal and distal risk factors
• Discussed the management of the suicidal
patient with regard to development and
implementation of a safety plan
• Reviewed empirical data base on interventions
to decrease risk of suicidal behavior