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44 Cards in this Set

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

multifactorial

risk varies over life of individual

predictors of suicide attepts overlap with predictors of suicide.
Which group is at highest risk for death by suicide?
Previous attemptors of suicide
Definition of Suicide Attempt
1)behavior that is DANGEROUS TO SELF

2)accompanied by INTENT TO DIE
Epidemiology of Suicide Attempts in US
200 to 600/100,000 per year
Clinical characteristics of suicide attemptor
-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
Protective Factors

e.g.s

what do you do?
Reason for living

Pets
Religion
Family members

Can intervene by reenforcing reason for living
How does suicide risk vary across psychiatric and medical disorders?
Rank:
MDD: 20X
Substance abuse
Bipolar disorder
Opiod abuse
Dysthymic Disorder
Schizophrenic
Alcohol Abuse
Epilepsy
AIDS - 6.6X
MJ abuse
SCI
Huntingtons
Is suicide always associated with psychiatric disorder?
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.
What predicts suicide in a primary care population?
Mood disorder, substance abuse, psychosis
***History of suicide attempt
Moderators of suicide risk
situational (life events, chronic stressors)

demographic (age, sex, income, etc.)
What predicts suicide in a primary care population?
BIG PICTURE
Long-term (chronic) risk factors
+
Short-term (acute) risk factors
Long-term (chronic) background features of suicide:
prior attempt
male
living alone
limited social contacts
lack of dependents
financial hardship
Short-term (acute) acute stressors of suicide:
interpersonal loss or conflict
other stressful events
Clinical/Psychiatric Risk Factors-- Long-term (Chronic)
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
Clinical/Psychiatric Risk Factors-- Short-term (Acute)
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)
General Medical Risk Factors:
Mostly chronic diseases
Screening of Long-term Risk:
History of suicide attempt and its context

History of high risk indicators
Assessment of Acute Risk:
Current clinical state

Current suicidal ideation and planning

Attitudes toward suicide

Context similar to prior suicide attempts
Primary Care/Emergency Medicine Screening for Suicidal Behavior

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
Screening of Long-term Suicide Risk:
History of suicide attempt and its context
History of high risk indicators
Assessment of Acute Suicide Risk:
Current clinical state

Current suicidal ideation and planning

Attitudes toward suicide

Context similar to prior suicide attempts
Brief Screening Questions:
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?
Primary Care/Emergency Medicine Screening for Suicidal Behavior

(2 steps)
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
guidelines for acute risk of sucide
monitor, contain and secure means for safe transfer to psychiatric inpatient service

Record results in medical chart
guidelines for chronic (non-acute) risk of sucide
refer for mental health treatment and schedule follow-up check (by phone or in person) on follow-through

Record results in medical chart
Behavioral Health Assessment of Acute Risk for Suicidal Behavior
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
Behavioral Health Assessment of Long-term Risk for Suicidal Behavior
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
Paykel Suicide Screening(for Behavioral Health)
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?
In psychiatry -- When chronic (non-acute) risk is indicated:
-conduct thorough history of prior attempt(s)
-familiarize with the clinical and psychosocial context for suicide attempts
Patient with Current Acute Risk--Intervene to:
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)
3 Components of Clinical Management of Long-term Risk:
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
Promote Key Protective Factors in Therapy
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
periodic screening will identify chronic, more often than acute, risk
T/F
T
For those with diagnosed mental health disorders and receiving care in behavioral health settings, frequent, brief inquiries about suicidality may be useful.
T/F
T
It is recommended to use two brief screening instruments for probing suicidality. What are they?
(two questions from the PRIME-MD and the five questions from the Paykel Scale)
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 ______________
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.
For those in mental health care:
suicidality should be First-level assessments should
_____________________

First-level assessments should _________
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)
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)
21 times
________ and ________ accounted for the association between severe mental illness and arrests (Robins, 1993)
Personality disorder and substance abuse
Treatment non-adherence increases risk for violence in mentally ill T/F
T
What are risk factors for violence among those with severe mental illness?
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
Age groups most victemized by violence
infants

15-35
risk factors for violent behavior
-history of previous violence or aggressive behavior
-family history of violence, personal abuse
-antisocial personality disorder or psychopathy
-history of alcohol or drug abuse