Suicide Risk Identification And Prevention In Primary Care

Front 1

Four key reasons why prediction of suicide in the individual is so difficult?

Back 1

Low base rates

multifactorial

risk varies over life of individual

predictors of suicide attepts overlap with predictors of suicide.

Front 2

Which group is at highest risk for death by suicide?

Back 2

Previous attemptors of suicide

Front 3

Definition of Suicide Attempt

Back 3

1)behavior that is DANGEROUS TO SELF

2)accompanied by INTENT TO DIE

Front 4

Epidemiology of Suicide Attempts in US

Back 4

200 to 600/100,000 per year

Front 5

Clinical characteristics of suicide attemptor

Back 5

-current psychiatric disorder

-comorbid substance abuse condition

-current chronic or life-threatening medical disorder

-in a small minority - no psychiatric disorder but acute emotional reaction to a recent life stressor

Front 6

Protective Factors

e.g.s

what do you do?

Back 6

Reason for living

Pets
Religion
Family members

Can intervene by reenforcing reason for living

Front 7

How does suicide risk vary across psychiatric and medical disorders?
Rank:

Back 7

MDD: 20X
Substance abuse
Bipolar disorder
Opiod abuse
Dysthymic Disorder
Schizophrenic
Alcohol Abuse
Epilepsy
AIDS - 6.6X
MJ abuse
SCI
Huntingtons

Front 8

Is suicide always associated with psychiatric disorder?

Back 8

in 90 to 95 percent of cases, disorder on Axis I or II is present

absent the above (i.e. in the other 5 to 10 percent) it is associated with ACUTE CRISES or MEDICAL ILLNESS.

Front 9

What predicts suicide in a primary care population?

Back 9

Mood disorder, substance abuse, psychosis
***History of suicide attempt

Front 10

Moderators of suicide risk

Back 10

situational (life events, chronic stressors)

demographic (age, sex, income, etc.)

Front 11

What predicts suicide in a primary care population?
BIG PICTURE

Back 11

Long-term (chronic) risk factors
+
Short-term (acute) risk factors

Front 12

Long-term (chronic) background features of suicide:

Back 12

prior attempt
male
living alone
limited social contacts
lack of dependents
financial hardship

Front 13

Short-term (acute) acute stressors of suicide:

Back 13

interpersonal loss or conflict
other stressful events

Front 14

Clinical/Psychiatric Risk Factors-- Long-term (Chronic)

Back 14

history of suicide attempt

history of major depression or bipolar disorder

history of alcohol or drug abuse

schizophrenia/schizoaffective disorder

personality disorder (Cluster B)

family history of suicide

history of aggressive (externalizing) behavior

pattern of impulsive behavior

Front 15

Clinical/Psychiatric Risk Factors-- Short-term (Acute)

Back 15

current depression
current substance abuse or impulsive overuse
acute psychic distress (including anxiety, panic)
extreme humiliation/disgrace
hopelessness
demoralization
desperation/sense of ‘no way out’
inability to conceive of alternate solutions
break-down in communication/loss of contact with significant other (including therapist)

Front 16

General Medical Risk Factors:

Back 16

Mostly chronic diseases

Front 17

Screening of Long-term Risk:

Back 17

History of suicide attempt and its context

History of high risk indicators

Front 18

Assessment of Acute Risk:

Back 18

Current clinical state

Current suicidal ideation and planning

Attitudes toward suicide

Context similar to prior suicide attempts

Front 19

Primary Care/Emergency Medicine Screening for Suicidal Behavior

Step 1. Assess current acute risk

Back 19

Current depression or demoralization?

Current suicidal ideation?

Planning?

History of suicide attempt(s)? When?

Under what circumstances?

Are those circumstances present now?

If yes, and there is current suicidal ideation, then request immediate emergency referral

Front 20

Step 2. Identify long-term risk indicators

Back 20

History of suicidal behavior?
History of depressive disorder?
History of alcohol or drug abuse?

Record the specific risk indicators for this individual in the medical chart

Front 21

Screening of Long-term Suicide Risk:

Back 21

History of suicide attempt and its context
History of high risk indicators

Front 22

Assessment of Acute Suicide Risk:

Back 22

Current clinical state

Current suicidal ideation and planning

Attitudes toward suicide

Context similar to prior suicide attempts

Front 23

Brief Screening Questions:

Back 23

In the last two weeks, have you had thoughts that you would be better off dead?

In the last two weeks, have you had thoughts of hurting yourself in some way?

In the last two weeks, have you made any attempt to hurt yourself? Any plan to do so? Have you ever made an attempt?

Front 24

Primary Care/Emergency Medicine Screening for Suicidal Behavior

(2 steps)

Back 24

Step 1. Assess current acute risk

-Current depression or demoralization?
-Current suicidal ideation? Planning?
-History of suicide attempt(s)? When?
-Under what circumstances? Are those circumstances present now?
If YES, and there is current suicidal ideation, then REQUEST IMMEDIATE EMERGENCY REFERRAL.

Step 2. Identify long-term risk indicators

-History of suicidal behavior?
-History of depressive disorder?
-History of alcohol or drug abuse?

Record the specific risk indicators for this individual in the medical chart

Front 25

guidelines for acute risk of sucide

Back 25

monitor, contain and secure means for safe transfer to psychiatric inpatient service

Record results in medical chart

Front 26

guidelines for chronic (non-acute) risk of sucide

Back 26

refer for mental health treatment and schedule follow-up check (by phone or in person) on follow-through

Record results in medical chart

Front 27

Behavioral Health Assessment of Acute Risk for Suicidal Behavior

Back 27

Step 1. Evaluate current state indicators:
-depression, demoralization or sense of desperation or panic

Step 2. Evaluate current suicidal ideation:
-how strong is the will to live?
-how strong is the will to die?
-is there any passive ideation?

Step 3. If ‘yes’ to current suicidal ideation:
- Is there a plan?
- Are the means readily available?

Step 4. What is the person’s attitude toward suicide?
-accepting, rejecting, ambivalent?

Step 5. Evaluate previous attempt history

Front 28

Behavioral Health Assessment of Long-term Risk for Suicidal Behavior

Back 28

Step 1. Identification of long-term risk indicators (by history)

-History of depressive episode(s)?
-History of alcohol or drug abuse?
-History of suicide attempt?
-What was the clinical and psychosocial context of the attempt? These are SPECIFIC RISK INDICATORS

Record the specific risk indicators for this individual in the medical chart

Front 29

Paykel Suicide Screening(for Behavioral Health)

Back 29

1. Has there been a time in the last year when you felt life was not worth living?

2. Has there been a time in the last year when you wished you were dead, for instance, that you would go to sleep and not wake up?

3. Has there been a time in the last year that you thought of taking you own life, even if you wouldn’t really do it?

4. Has there been a time in the last year when you reached the point where you seriously considered taking your own life, or perhaps made plans how you should go about doing it?

5. Was there ever a time that you made an attempt on your own life? (if yes) When was that?

Front 30

In psychiatry -- When chronic (non-acute) risk is indicated:

Back 30

-conduct thorough history of prior attempt(s)
-familiarize with the clinical and psychosocial context for suicide attempts

Front 31

Patient with Current Acute Risk--Intervene to:

Back 31

ensure IMMEDIATE SAFETY (do not hesitate to refer for inpatient evaluation)

treat ACUTE RISK FACTORS(current depression, psychosis or anxiety)

remove/minimize AVAILABILITY OF MEANS (e.g. remove pills, guns, etc.)

treat CRONIC(long-term) RISK FACTORS(e.g. prophylactic/ continuation treatment of depression)

Enhance PROTECTIVE factors (e.g. engage family)

Front 32

3 Components of Clinical Management of Long-term Risk:

Back 32

1) PHARMACOLOGIC/SOMATIC TREATMENTS for a clinical disorder associated with high risk (e.g. depression, bipolar disorder, psychosis)

2) PROPHYLACTIC PSYCHOSOCIAL TREATMENTS to enhance coping behaviors (e.g. cognitive behavioral therapy and problem-solving skills therapy)

3) ONGOING MONITORING OF RISK in the patient at long-term high-risk

-referral to behavioral health

-‘ready’ communication between primary care and behavioral health teams

-engage patient and significant others in monitoring “early warning signs” of the emergence of acute risk factors

Front 33

Promote Key Protective Factors in Therapy

Back 33

Subjective reasons for living

Current availability of clinician

Removal of lethal means (guns, pills, etc.)

Daily social contacts

Responsibilities for dependent others

Attitudes toward suicide

Front 34

periodic screening will identify chronic, more often than acute, risk
T/F

Back 34

T

Front 35

For those with diagnosed mental health disorders and receiving care in behavioral health settings, frequent, brief inquiries about suicidality may be useful.
T/F

Back 35

T

Front 36

It is recommended to use two brief screening instruments for probing suicidality. What are they?

Back 36

(two questions from the PRIME-MD and the five questions from the Paykel Scale)

Front 37

For those in primary and specialty medical care:
those who respond positively to “better off dead” should __________.

Those who respond positively to “hurting yourself” should ______________

Back 37

be evaluated for mental health service needs by either the medical provider or by referral to behavioral health

be evaluated on an URGENT basis by a behavioral health provider.

Front 38

For those in mental health care:
suicidality should be First-level assessments should
_____________________

First-level assessments should _________

Back 38

be evaluated on a periodic basis and whenever indicated on the basis of each patient’s clinical status.

rely on screening questions (e.g. those derived from the PRIME-MD)

Front 39

Epidemiologic Catchment Area survey data reported that individuals with schizophrenia are _______ more likely than others to report use of weapon in a fight (Swanson et al., 1990)

Back 39

21 times

Front 40

________ and ________ accounted for the association between severe mental illness and arrests (Robins, 1993)

Back 40

Personality disorder and substance abuse

Front 41

Treatment non-adherence increases risk for violence in mentally ill T/F

Back 41

T

Front 42

What are risk factors for violence among those with severe mental illness?

Back 42

The same risk factors for violence in the general community—
-Alcohol or drug abuse
-Antisocial personality disorders
-Unstable work
-Separation from biological parents
-Early history of abuse or domestic violence

Front 43

Age groups most victemized by violence

Back 43

infants

15-35

Front 44

risk factors for violent behavior

Back 44

-history of previous violence or aggressive behavior
-family history of violence, personal abuse
-antisocial personality disorder or psychopathy
-history of alcohol or drug abuse