Transcript Suicide Risk Assessment and Prevention: An Update on the

Assessment and
Management of Suicide
Risk
May 24, 2007
Melissa J. Pence, Psy.D.
Licensed Clinical Psychologist
Hampton Roads Neuropsychology and Behavioral Medicine
Outline
1.
2.
3.
4.
5.
6.
7.
Impact
Demographics and epidemiology
Etiology
Risk assessment
Psychological Testing
Treatment and prevention
Medical-legal concerns
A personal account of the impact
of suicide
• " His light, through
me, will grow as a
beacon for others."
John C. Gibbs
http://www.INeedALighthouse
.com/index.html
Survivors of Suicide
(Schneidman, 1969)
Survivor
Survivor
Survivor
Suicide Victim
Survivor
Survivor
Survivor
Suicide
•
Definition of suicide:
“Suicide is the death resulting directly or
indirectly from a positive or negative
act of the victim himself, which he knows
will produce this result.” Emile Durkheim
•
Requires:
1. Death/lethal outcome
2. Self-inflicted
3. Intentionally inflicted
4. Awareness or consciousness of
outcome
Problems in studying suicide
• Low base rate
• No test (biological or psychological)
or clinical marker that predicts
suicide
• Requires clinical judgment
• Numerous false positives in
prediction paradigms
• High risk suicidal patients excluded
from most clinical studies
Demographics and
Epidemiology
A MAJOR Public
Health Problem!
How is this data gathered?
• Death certificate information reported
by each state to the National Center for
Health Statistics
• Most recent national data available is
2003
• Numbers are generally understood to be
a modest underestimation of actual
suicide deaths due to difficulties in
conclusively determining cause of
death
U.S. National Statistics (2003)
•
•
•
•
•
(CDC)
31,484 deaths by suicide
86 deaths per day
1 every 17 minutes
11th leading cause of death
Approximately 787,000 attempts, ratio
25:1
• Twice as many people die by suicide
than by homicide
Statistics (2003)
Number
Per
Day*
Rate
% of Deaths
Nation
31,484
86.3
10.8
Males
25,203
69.0
Females
6,281
Whites
(CDC)
Group (Number of Suicides)
Rate
1.3
White Male (22,830)
19.5
17.6
2.1
White Female (5,655)
4.7
17.2
4.3
0.5
Nonwhite Male (2,373)
9.1
28,485
78.0
12.1
1.4
Nonwhite Female (626)
2.2
Nonwhites
2,999
8.2
5.5
0.9
Black Male (1,597)
8.8
Blacks
1,955
5.4
5.1
0.7
Black Female (358)
1.8
Elderly (65+
yrs.)
5,248
14.4
14.6
0.3
Hispanic (2,007)
5.0
Young (15-24
yrs.)
3,988
10.9
9.7
11.9
Native American (322)
10.4
Asian/Pacific Islander (722)
5.5
State by State Rate
Comparisons
Firearms are the Leading Method
of Suicide (2003)
Suicide Methods:
Firearm suicides
Suffocation/Hanging
Cut/Pierce
Percent
of Total
Number
Rate
Number
Rate
16,907
5.8
53.7%
All but
Firearms
6,635
2.3
21.1%
571
0.2
1.8%
Percent of Total
14,577
5.0
46.3%
Poisoning
5,462
1.9
17.3%
Drowning
339
0.1
1.2%
Data on Means of Suicide (2001)
Youth Suicide Rates
• 3rd leading cause of death in those aged
15-24, behind only accidents and
homicide.
• 2nd leading cause of death in college
students.
• 6th leading cause of death in 5-14 year
olds.
• Ratios of attempts to completions
estimated to range between 100:1 to 200:1
• In 2001, firearms were used in 54% of
youth suicides.
Youth Suicide
•In 1999, 20% of HS
students reported
seriously considering
suicide and 8% attempted.
•Frequent drug and
alcohol abuse was found
to be the most common
characteristic in young
people who attempted
suicide (Department of Education)
Youth Statistics (2003)
Age
Group
Number of
Suicide Rate
Suicides
10-14 yrs
244
1.2
15-19 yrs
1,487
7.3
20-24 yrs
2,501
12.1
Suicide in the Elderly
–Higher Completion rates
(1:4) over age 65.
–Medical illness a
significant factor in 70%
of suicides over age 70.
–Most saw a physician
within a few months of
their death and 1/3 within
the previous week.
–Rate of suicide is 14.8
per 100,000 when
compared to 10.8 per
100,000 in general
population.
Male Suicide Rates
•8th leading cause of
death (2003)
•4 times more likely to
die by suicide than
females
•60% of suicides
involve the use of a
firearm
•Rates are relatively
constant between
ages 20-64, but
increase sharply after
age 65.
Female Suicide Rates
•Women attempt
suicide twice as often
as men. Some studies
suggest the rate is
closer to 3:1.
•One woman attempts
suicide every 78
seconds in the U.S.
•Rates peak between
the ages of 45-54
(around time of
menopause) and again
after age 75.
Suicide Deaths per 100,000
SUICIDE MORTALITY – 2000
60
Female
White Male
50
40
30
20
10
0
00-04 05-09 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
National Center For Health Statistics.
National Vital Statistics Reports.
Breakdown by Race
• Caucasians are over 2x more likely to
complete suicide than African
Americans (AA).
• AA males comprised 84% of suicide
deaths in that racial group.
• Firearms predominant method
among AAs, regardless of gender.
• American Indian and Alaskan native
men have the 2nd highest rate of
suicide after Caucasians.
Etiology
Neurobiology
Cognitive Psychology
DiathesisStress
Model
THE NEUROBIOLOGY OF SUICIDAL
BEHAVIOR
Familial and Genetic Factors
•There is a
transmission of
familial and genetic
factors that
contribute to risk for
suicidal behavior.
•Major psychiatric
illnesses, such as
MDD, schizophrenia,
and alcoholism have
genetic component
in etiology.
Familial and Genetic Factors
• Several studies have found genetic and
familial transmission risk is independent of
transmission of psychiatric illness.
• First degree relatives of individuals
(including dizygotic twins) who have
completed suicide have more than 2x the
risk of the general population.
– For monozygotic twins, risk increases to 11x.
(Quin, Agenbo, & Mortensen, 2002)
• Recent study could not find genetic effect
on suicidal ideation. (Farmer et al, 2001)
Studies on the Serotonergic System
• Difficult area to study, numerous
methodological problems.
• There is evidence of modest reductions in
in brain stem/prefrontal cortex serotonin or
its marker 5-HIAA (metabolite).
• Lower CSF (cerebral spinal fluid) 5-HIAA
levels has been reported by most studies
in patients with a history of suicide attempt
and a diagnosis of MDD, Schizophrenia, or
PD compared to control groups of patients
with these diagnoses.
Serotonergic system, continued
•Low CSF 5-HIAA level
predicts higher rate of past
and future suicidal acts as
well as seriousness of
suicidal acts over the lifetime.
•PET scans can map
serotonin-induced changes in
brain activity.
–Size of abnormality in anterior
cingulate and prefrontal cortex
is proportional to lethality.
(Oquendo et al., 2003)
Noradrenergic System
• Reduced noradrenergic functioning is
suggested, however the evidence is not as
strong as in the serotonergic system.
• The conclusion: there is a period of
noradrenergic over-activity (which may be
a stress response and state dependent)
prior to suicide which contributes to NE
depletion.
The Diathesis- Stress Model
•Proposed by Zubin and Spring (1977)
•An individual has unique biological,
psychological and social elements.
These elements include strengths and
vulnerabilities for dealing with stress.
The Diathesis-Stress Model
Beck’s Cognitive Model
(1967)
• Schema: tacit beliefs and memory
structures that serve to organize the
encoding, retrieving, and processing
of information
– Latent much of the time
– May be activated by specific life events
– Develop from an early age
– Reinforced and consolidated by life
events
Schema of depressed individuals
thought to be rigid, negativistic toward
self and others, future is bleak, lack
control over outcomes.
Beck’s Cognitive Model, Continued
• Cognitive distortions most frequently
associated with suicidal ideation:
– Cognitive constriction or tunnel vision
– Polarized or all or nothing thinking
– Selective recall of past failure and
overlooking past success
These are believed to play a role in
development and maintenance of
dysfunctional attitudes and irrational
beliefs.
CONDUCTING A
SUICIDE RISK
ASSESSMENT
What is a Suicide Risk Assessment?
• “Refers to the establishment of a
clinical judgment of risk in the very
near future, based on the weighing of
a very large mass of available clinical
detail.”
• “More than a guess or intuition- it is a
reasoned, inductive proceess.”
• “A necessary exercise in estimating
probability over short periods.”
From Jacobs, 2003
Who should receive a suicide assessment?
• ANY patient who meets criteria for
DSM-IV mental or substance use
disorder(s).
• Should initially occur at the point of
entry into treatment (i.e. initial visit or
intake) and periodically as clinically
indicated.
• If the patient meets criteria for a
depressive disorder and/or manifests
any degree of suicide lethality, they
should be assessed each session.
Two Components of Assessment
PART 1:
The elicitation and elaboration
of suicidal ideation
PART 2:
The identification and
qualification of risk factors for
completed suicide
Part 1: Assessing Suicidal Ideation
• Begin with general questions about
self-harm, such as asking whether the
patient has had thoughts of death or
suicide. Ask them to elaborate in their
own words and describe what these
thoughts are like. Use open ended
questions.
• Thoughts should be characterized as
active (“When I am walking, I get the
impulse to jump out into traffic”) or
passive (“Everyone would be better of if
I was dead”).
Assessing Suicidal Ideation, Continued
•If suicidal thoughts
are present, assess
how often and in
what context they
occur.
•Are they fleeting,
periodic, or
persistent? Are the
situation specific?
Are they increasing
or decreasing in
intensity?
Assessing Suicidal Ideation, Continued
• The patient should be asked if they
have a plan, or if they have thought
of a means in which they would use
to carry out suicide.
– Method (availability, lethality)
– Suicide notes, final acts in
preparation for death (i.e. will
preparation)
– Has mental rehearsal taken place? Is
there a plan for a time or place?
– Have any attempts been made thus
far?
Assessing Suicidal Ideation, Continued
• History of similar thoughts,
impulses, plans, aborted attempts
and/or attempts should be
obtained.
• Corroborating report from family or
providers should be obtained (if
possible).
Assessing Suicidal Ideation, Continued
– Confidentiality can legally be broken to
obtain appropriate care if you have
evidence to suggest the patient is
acutely a danger to himself or others.
• Usually necessary information can be
obtained by simply listening to the family
members and it may not be necessary to
reveal private or confidential information to
the family.
• However, in some situations you may be
obligated to break confidentiality to protect
the patient. Remain sensitive to family
issues and disclose necessary information
to protect the patient.
• Helps to discuss this during informed
consent at the beginning of the process.
Assessing Suicidal Ideation, Continued
• Determine if there are any barriers
to suicide.
– What are the patient’s reasons
for living and reasons for dying?
– How has the patient managed to
evade the act of suicide thus
far?
• Assess level of current supports
(family, significant other, friends,
employer, therapist, etc.)
Part 2: Assessing Risk
Factors
“Risk Factor” Defined
• Leading to or being associated with
suicide
• Individuals possessing the risk factor
are at greater potential for suicidal
behavior
• Some risk factors can be changed or
reduced (i.e. providing Lithium
treatment for Bipolar Disorder),
others are static (The patient’s father
completed suicide)
• From Suicide Prevention Resource Center, www.sprc.org
Presence of a mental disorder
•Present in over 90% of
completed suicides.
•High risk diagnoses are:
–Depression (unipolar and
bipolar)
–Alcohol/substance abuse or
dependence
–Schizophrenia
–Borderline Personality
Disorder
Co-morbidity increases risk!
• Psychological autopsy studies of 229
suicides:
– 44% had 2 or more Axis I diagnoses
– 31% had Axis I and Axis II
diagnoses
– 50% had Axis I and at least one
Axis III diagnosis
– 12% had an Axis I diagnosis with
no co-morbidity
From Henriksson et al, 1993
Recent psychiatric hospitalization
•Within the last year
•Acute exacerbation
of illness
The presence of depression
•Including
hopelessness, guilt,
loss
•Global insomnia
Note: Hopelessness
has been found to be
co-occurring with
depression as well as
a predictor of
suicidal ideation and
behavior.
Recent or impending loss
– Loss of job
– Loss of relationship
– Loss of loved one, grief
– Recent move (CDC, 2002)
– Humiliating events, such as financial
ruin due to a scandal, being arrested or
being fired, can lead to impulsive
suicide (Hirschfeld and Davidson, 1998)
Substance or alcohol use
•
•
Up to 50% of those completing
suicide drinking alcohol at time
of death.
Drinking within three hours of
the attempt was the most
important alcohol-related risk
factor for nearly lethal suicide
attempts, more important than
alcoholism and binge drinking.
(CDC, 2002)
– CNS depressants increase risk.
(Wines et al, 2004)
History
• History of impulsive or dangerous
behavior, and/or history of suicide
attempts
– Severe self-mutilation
– A history of serious suicide attempts
may be the best single predictor of
completed suicide; the greatest risk
occurs within 3 months of the first
attempt.
– HOWEVER, the majority of suicides
are in individuals with no prior
attempts.
Access to firearms
• 92% of suicide attempts by firearm
are successful
• Keeping firearms in the home
increases the risk of suicide for
both genders even after other
factors, such as depression and
alcohol use, are controlled for.
Family history of suicide
• First degree relatives = more than 2x
the risk of the general population
– For monozygotic twins, risk = 11x.
Social isolation or withdrawal
•Having a strong
preference for
being alone
(change from
previous behavior)
•Withdrawing from
family, social, or
volunteer activities
•Not keeping
appointments
Concurrent medical disorder
Characterized by:
• chronicity,
•poor prognosis,
•disfigurement
and/or
•persistent pain.
Medical illness, continued
• Diagnoses most associated with
completed suicide:
–
–
–
–
–
–
–
–
–
Huntington’s Chorea
Malignant Neoplasms
Multiple Sclerosis
Renal disease
Peptic Ulcers
Spinal Cord injuries
Lupus
HIV/AIDS
Epilepsy (only medical diagnosis
documented to increase risk in children
and adolescents)
Severe agitation/anxiety
•Panic attacks, severe
psychic anxiety, and global
insomnia all significantly
associated with suicide at
one year follow up. (NIMH)
•Behavioral signs: pacing,
wringing hands, rocking,
severe restlessness, etc.
•Assess for treatment
responsive acute risk
factors, such as askathsia.
From Jacobs (2003), Harvard Medical School
RISK FACTORS (blue = modifiable)
Demographic
male; widowed, divorced, single; increases with age; white
Psychosocial
lack of social support; unemployment; drop in socioeconomic status; firearm access
Psychiatric
psychiatric diagnosis; comorbidity
Physical Illness
malignant neoplasms; HIV/AIDS; peptic ulcer disease;
hemodialysis; systemic lupus erthematosis; pain syndromes;
functional impairment; diseases of nervous system
Psychological
Dimensions
hopelessness; psychic pain/anxiety; psychological turmoil;
decreased self-esteem; fragile narcissism & perfectionism
Behavioral
Dimensions
impulsivity; aggression; severe anxiety; panic attacks;
agitation; intoxication; prior suicide attempt
Cognitive
Dimensions
thought constriction; polarized thinking
Childhood
Trauma
sexual/physical abuse; neglect; parental loss
Genetic &
Familial
family history of suicide, mental illness, or abuse
Depression: Unipolar and Bipolar
•The lifetime risk
for suicide in
patients with
mood disorders
(major depressive
disorder and
bipolar disorder)
is approximately
15-19%, and the
risk is highest in
the early stages of
the illness.
Major Depression
• Factors to consider:
– The concurrent presence of anxiety
– Substance abuse or dependence
– Command hallucinations
– Irritability or anger associated with
impulsivity
– Severe insomnia, especially global
insomnia
– Presence of or access to a gun
(Jones et al, 2000)
Bipolar Disorder
(Goodwin & Jamison, 1990)
•Risks:
–Severe depression with anxiety,
agitation
–Global insomnia
–Substance abuse
–Transition periods/early recovery phase
–Impulsive or violent behavior
Bipolar Disorder, continued
– Assess current mood:
• Typically rates < 2% during
psychotic mania (Dilsaver, 1997)
• 11% directly after remission from
mania (Goodwin, 2002)
• Approximately 79% during major
depressive episode (Goodwin, 2002)
• 11% during mixed state (Goodwin,
2002)
Alcohol/Substance Abuse or Dependence
• The suicide risk among patients suffering
from alcoholism is similar to that in patients
with mood disorders, but they tend to
commit suicide late in the course of
alcoholism and are frequently depressed at
the time of death.
Two factors affecting risk (Weiss & Hufford,
1999)
1.Effects of acute intoxication
2.Co-morbid psychopathology such as
MDD
• Risk with recent or anticipated
interpersonal loss
Schizophrenia
(Tsuang, Fleming, & Simpson, 1999)
•Risk Factors for suicide
in psychotic patients:
–Young age (<30)
•#1 cause of death
for young people Dx
with Schizophrenia
–Good intellectual
functioning
–Disillusion with
treatment
–Good premorbid
functioning
–Early stage of illness
–Communication of
intent
–Frequent exacerbations
and remissions
–Painful awareness of
the likely degree of
chronic disability in the
future
–Periods of clinical
improvement following
relapse
–Supervention of a
depressive episode and
increased hopelessness
Timeline of Risk
Borderline Personality Disorder
• Most likely associated with parasuicidal
rather than suicidal acts:
– HOWEVER approximately 8.5% of patients
eventually commit suicide, usually after
multiple attempts or gestures.
– Nearly 75% of patients make one attempt
in lifetime.
– With alcohol problems=19%
– Per Stone (1993) with alcohol + major
affective D/O=38%
– Usually qualify for a co-morbid Axis I diagnosis at
the time of death.
• Hx of childhood sexual abuse increases the
amount and lethality of parasuicidal
behaviors.
Identify Chronic vs. Acute Risk
•Acute:
–New, acute
presentation
–Presence of significant
stressor
–Emergent response to
acute crisis of mood and
despair
–Possible co-morbid
Axis I disorder
•Chronic:
–Recurrent and
persistent suicidal
thoughts that
provide an ongoing
psychological
mechanism for
coping with distress
–Frequent, usual
response to life
stresses and
disappointments
–Patient may be
aware of chronicity
Protective Factors
• Protective factors are believed to
enhance resilience and serve to
counterbalance risk factors.
– An individual's genetic/neurobiological
make-up
– Attitudinal/behavioral characteristics
– Family/community support
– Effective and appropriate clinical care
for mental, physical and substance
abuse disorders
– Pregnancy or children in the home,
except for post-partum illness
Protective Factors, continued
– Easy access to effective clinical
interventions and support
– Restricted access to highly lethal methods
of suicide
– Cultural and religious beliefs that
discourage suicide and support selfpreservation instincts
– Support from ongoing medical/mental
health care , positive therapeutic
relationship
– Acquisition of learned skills for problem
solving, conflict resolution and non-violent
management of disputes.
Prevention and Treatment
Strategies
Therapeutic Treatment Strategies
No Suicide Contracts
Pharmcotherapy
Hospitalization
Prevention/Treatment Strategies
• ASSESS, ASSESS, ASSESS
– Assess acute vs. chronic risk
• 24 hour access to crisis care
• Strong therapeutic alliance is
ESSENTIAL!
• Work with family and other support
systems
• Use multiple resources,
multidisciplinary approach
Access to Services
• Crisis services by phone
– National Hotline
• 1(800) 273-TALK
• Emergency Department
Prevention/Treatment Strategies
• Short term coping strategies,
behavioral treatments
–
–
–
–
Deep breathing
Relaxation training
Imagery training
Grounding
• Specific, concrete, written safety
plan in place and frequently
renewed and reviewed
– Access to means removed immediately
Dialectical Behavioral Therapy (Linehan, 1993)
• Developed by Linehan for patients Dx
w/ BPD and engaging in self-harm
behaviors
• Philosophical orientation focuses on
dialectics
– Move from dichotomous thinking to
balance
• Patients learn to observe and
describe, be non-judgmental and
focus on the present, and focus on
current activity
What is a no-suicide contract?
• Also known as no-harm contract
or safety contract.
• Involves an agreement in which a
patient makes a verbal or written
promise not to harm or kill
themselves.
• Commonly used by mental health
practitioners, including:
psychiatrists, psychologists,
nurses, social workers, and
therapists.
No-Suicide Contracts Usually Contain
• An explicit statement not to harm
or kill oneself.
• A specific duration of time.
• Contingency plans if contract
conditions cannot be kept.
No Suicide Contracts
• When the patient doesn’t agree….
• If the patient can not or will not agree to
the terms of the negotiated contract or if
non-verbal/historical cues contradict the
agreement, he/she is usually considered
to be at- risk.
• In the presence of a strong therapeutic
alliance when manipulative behavior is
suspected, this should be further
explored.
History of NSCs
• First documentation in 1973 in study by Drye,
Goulding, & Goulding.
• Surveyed 31 counselors reporting on 609
patients, 266 of whom were judged “seriously
suicidal”. 24 suicides or serious attempts
were reported where their method for
assessment was NOT used and 4 deaths
occurred where their method was used.
• Method= When counselor became aware of SI,
asked client to repeat, “No matter what
happens, I will not kill myself, accidentally or
on purpose, at any time” (p.172) Then client
discussed his/her reaction to the statement.
• Objections or alterations were deemed at risk.
No Suicide Contracts: Potential Pitfalls
Pitfall #1
• BELIEVING THAT A SIGNED SUICIDE
CONTRACT ELIMINATES SUICIDE
RISK
– Suicide cannot be absolutely predictedFalse sense of security.
– There is no data demonstrating its
effectiveness or its acceptance in the
professional community. (Drew, 2001)
– In one study, 41 percent of
psychiatrists had patients who
committed suicide or made serious
attempts after entering into a NSC. (Kroll,
2000)
Pitfall #2
• CONTRACT: THE LEGAL TERM
– Clinicians may wish to consider
avoiding the word “contract” in their
medical documentation.
– The term may also appear to attempt to
free the clinician from blame for suicide
attempts/completions.
– Appropriate clinical assessment and
intervention, rather than liability
prevention, should be the focus of care.
• Outcomes of legal cases and judgments about
clinician’s care are improved by demonstration of
comprehensive assessment and treatment.
Pitfall #3
• INFORMED CONSENT???
– Informed consent is a legal and
ethical doctrine involving the
disclosure of risks, alternatives, and
facts that allow a patient to make
informed and unpressured decisions
about treatment options.
– The competency of a patient to
understand what they are signing or
to give informed consent to such an
agreement during a time of crisis is in
question.
Who may or may not be capable of giving informed consent?
Diagnosis
Cited in…
Cerebral Impairment
Drye et al (1973)
Psychosis
Goulding (1979)
Egan (1997)
Under the influence of
drugs/alcohol
Goulding (1979)
Egan (1997)
Impulse control
deficiencies
Davidson et al (1995)
Motto (1979)
Severe Depression
Egan (1997)
Simon (1999)
Informed Consent: Farrow & O’Brien (2003)
• VERY limited data in this area
• Their study concluded that most patients
interviewed were not able to participate in
informed consent for a NSC at the time of
suicidal crisis.
• In retrospect, most subjects doubted their
competence to enter a NSC at the time of
crisis. “My thinking was so confused. I
did not understand what they were
suggesting.”
• Participants reported a strong sense of
being coerced by clinician.
Pitfall #4
• A safeguard against liability???
– A NSC may be used as a means to reduce
the evaluator or therapist’s anxiety
regarding litigation.
– Frequently charted phrases or shorthand
such as “contracted for safety” should be
avoided without appropriate ancillary
documentation (suicide risk assessment,
basis for clinical judgment, plan for
managing risk.)
– Providers may believe that securing a NSC
completes an assessment of suicidality,
this is short sighted and legally
precarious.
• Range et al, 2000, Stanford et al, 1994, Weiss, 2001,
Miller, 1999, Miller et al, 1998, Lee & Bartlett, 2005
No Suicide Contracts: Potential Benefits
Benefits
1.
A means of evaluating current suicidality
– One part of a comprehensive suicide risk
evaluation.
– Opportunity to discuss suicidal feelings
directly.
2. Provision of specific behavioral alternatives to
suicidal acts.
– Written behavioral plan for patient in a crisis
situation
3. An adjunct to comprehensive evaluation and
treatment
– In the context of a sound and positive
therapeutic relationship
– The more concrete, the better! (i.e. written vs.
oral, specific behavioral strategies tailored to
the patient’s needs)
Bottom line about NSCs
– Use NSCs with caution,
understanding that they are one
part of a comprehensive suicide
risk assessment and treatment plan
and have not been demonstrated in
the literature to reduce suicide risk.
Pharmcotherapy
• There are reasons to believe that selective
serotonin reuptake inhibitors (SSRIs) might
reduce suicidality.
• SSRIs remain the preferred
psychopharmacological treatment for
depression.
• Lithium has a strong, and possibly unique
protective effect against suicidal acts in
patients with bipolar disorder. (Baldessarini & Tondo,
1999)
Pharmcotherapy
• Patients being treated with
psychotropic medication should
be closely observed for clinical
worsening:
–Agitation, irritability, suicidality,
and unusual changes in behavior,
especially during the initial few
months of a course of drug
therapy, or at times of dose
changes, either increases or
decreases.
From Jacobs (2003) Harvard Medical School
SOMATIC TREATMENTS
ECT
Evidence for short-term reduction of
suicide, but not long-term.
Benzodiazepines May reduce risk by treating anxiety
Antidepressants
A mainstay treatment of suicidal patients
with depressive illness / symptoms.
Lithium and
Lithium has a demonstrated anti-suicide
Anti-convulsants effect; anticonvulsants do not
Antipsychotics
Evidence for Clozapine reducing
suicidality in schizophrenia and schizoaffective disorders
Medical-legal Concerns
Litigation
• Bereaved survivors have a unique
grief, often feeling hurt, angry, and
possibly guilty.
• May seek compensation for their loss
through a claim of negligence.
• Number of lawsuits continues to rise.
• Hospitals are the primary target,
however there has been an increase
in number of claims against
outpatient providers.
A Shift in the Law
(Gutheil, 2000)
• Before 1940: Suicide was considered
an independent intervening cause of
death
• After 1940: But for the provider or
physician’s negligence, the patient
would not have committed suicide
(negligence as a proximate cause)
Medical-legal Concerns
• The law recognizes that there are no
standards for the prediction of suicide and
that suicide results from a complicated
array of factors.
• The standard of care for patients with
suicidality is based on the concept of
"foreseeability"
• Courts assume that a suicide is
preventable if it is foreseeable.
Medical- Legal Concerns
(Lee & Bartlett, 2005)
• Forseeability is defined as “A
comprehensive and reasonable
assessment of risk”
• Reasonable care involves
“Developing a comprehensive
treatment plan and timely
implementation based on the
assessment of risk, or forseeability”
• Failure to assess risk and make
sound judgments makes the provider
a possible target of litigation.
Risk Management
• Realistically, a clinician is not always able
to prevent a suicide in a determined
patient.
• Common themes identified in liability suits
include:
– lack of an ongoing, documented
assessment of suicide risk, especially
prior to hospital discharge, a change in
privileges, or a change in clinical status,
– lack of documentation to reflect a
clinical rationale regarding treatment
decisions, and
– inadequate patient supervision.
Documentation
• In the case of a lawsuit, the chart will be
examined.
• Although most lawsuits arise over
inpatients who commit suicide,
documentation of encounters with all
suicidal patients should include:
– Risk assessment
– Contacts with family members
– Contacts with other treatment providers
– Phone calls, letters
– Responses to failed appointments
– Non-compliance with treatment
Risk Management: Key Points
(Lee & Bartlett, 2005)
• Keep abreast of current legal and ethical
standards
• Develop and implement a policy for
handling crisis situations
–
–
–
–
24 hour availability of services
Increasing frequency or duration of sessions
Bring in supportive family/friends
Refer where appropriate for multidisciplinary
Tx
– Follow up for compliance and disposition
– Monitor medication allocation, access, and use
– Establish check-in system with the client
Risk Management: Key Points
(Lee & Bartlett, 2005)
• Maintain clinical competency
(continuing education, supervision,
consultation)
• Ensure accurate and thorough
documentation
• Develop relevant resources, such as
a network to consult with, community
programs, etc.
Postvention
• Immediately provide support to the family
• Consider attending funeral or writing letter
of condolence
– Serves both humanitarian and risk
management goals
• Care for yourself
– Understand your feelings (guilt, grief, anger,
fear, etc.)
– Discuss/consult/debrief with trusted colleague
or supervisor
Provider self-care
• Caring for suicidal patients can be
very taxing- emotionally and
physically!
• Remember to care for yourself:
– Eat a balanced nutritional diet, get
adequate sleep, exercise
– Seek personal counseling formally or
informally
– Consult appropriately with colleagues
and supervisors
• May wish to share personal emotional
reactions, burnout, and counter-transference
issues (Shea, 2002)
Questions or comments….