Assessing Risk for Suicide in the Primary Care Setting Presented by: Jonathan Betlinski, MD Date: 10/02/2014 1

Learning Objectives Disclosures and Learning Objectives Know the five steps of Suicide Assessment Know at least three screening tools Know ORS as it relates to involuntary holds placed outside hospitals Know at least two numbers to call Disclosures: Dr. Jonathan Betlinski has nothing to disclose. 2

Review risk factors for suicide Assessing for Risk of Suicide Review risk factors for suicide Review SAFE-T and other screening tools Reminder of legal responsibility Next Week's Topic 3

Risk Factors for Suicide Suicide is the 10th leading cause of death 2nd in age 25-34, 3rd in age 15-24 Suicide rate is 17.6 per 100,000 people The rate increased 30% from 1999 to 2010 Having a mood disorder increases risk 20x Mood disorders account for 50% Schizophrenia accounts for 14% Personality Disorders account for 14% http://www.nytimes.com/2013/05/03/health/suicide-rate-rises-sharply-in-us.html?_r=0 http://books.google.ca/books?id=fV8_1u0c7l0C&pg=PA31#v=onepage&q&f=false

More Risk Factors for Suicide 8.6% lifetime risk for psychiatric inpatients 20% of those who die have a prior attempt 1% of attempts will die within one year 5% of attempts will die in 10 years 25-40% got any MH services last year 20% saw an MHP in the last month 45% saw their PCP in the last month http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146379/pdf/mayoclinproc_86_8_011.pdf http://www.bbmh.manchester.ac.uk/cmhr/research/centreforsuicideprevention/nci

Suicide and Firearms People who have access to a firearm are three times more likely to commit suicide Men with home access to a firearm are four times more likely than women to commit suicide with a firearm Men with home access to a firearm are ten times more likely to die by suicide with a firearm then men with no home access Attempting suicide with a firearm results in death 90% of the time http://annals.org/article.aspx?articleid=1814426 http://www.mentalhelp.net/poc/view_index.php?idx=119&d=1&w=5&e=28649

SAFE-T (Suicide Assessment Five-step Evaluation and Triage) Identify Risk Factors Note those that can be modified Identify Protective Factors Note those that can be enhanced Conduct Suicide Inquiry Determine Risk Level/Intervention Document http://www.integration.samhsa.gov/images/res/SAFE_T.pdf

Identify Risk Factors Ideation – threatened or communicated Substance abuse – excessive or increased Purposeless – no reason for living Anxiety – agitation/insomnia Trapped – feeling there is no way out Hopelessness Withdrawing – from friends/family/society Anger (uncontrolled) – Rage, seeking Revenge Recklessness – risky acts, unthinking Mood Changes (dramatic) http://store.samhsa.gov/shin/content//SVP06-0153/SVP06-0153.pdf

Identify Protective Factors Internal Sense of responsibility Life satisfaction Positive Coping and Problems-solving Skills Reality Testing Ability External Children in the home and/or pregnancy Religiosity Positive Social Support Positive Therapeutic Relationship http://www.integration.samhsa.gov/images/res/SAFE_T.pdf http://psychiatryonline.org/content.aspx?bookID=28&sectionID=1673332#56073

Conduct Suicide Inquiry Ask the person directly if he or she Is having suicidal thoughts/ideas Has a plan to do so Has access to lethal means “Are you thinking about killing yourself?” “Have you thought of ways that you might hurt yourself?” Asking does not increase risk! http://store.samhsa.gov/shin/content//SVP06-0153/SVP06-0153.pdf

Determine Risk Level / Intervention NSW Risk Assessment Guide http://www0.health.nsw.gov.au/pubs/2004/pdf/community_mental_hlt.pdf CSUS Suicide Risk Assessment http://www.csus.edu/indiv/b/brocks/Workshops/District/2.Suicide%20Risk%20Assessment%20Su mmary.pdf ACP Assessment of Suicidal Ideation http://www.acponline.org/acp_press/essentials/cdim_ch30_wed05.pdf Harvard Risk Management Guidelines https://www.rmf.harvard.edu/Guidelines- Algorithms/2011/~/media/Files/_Global/KC/PDFs/suicideAs SAMHSA Grid http://www.integration.samhsa.gov/images/res/SAFE_T.pdf

Determination of Risk / Intervention BHS – ED MHTS MSHR ReACT Self Harm Rule Beck's SIS DSI – SS http://www.guideline.gov/content.aspx?id=47355 GDS RAM SIQ SIQ – JR VASA NGASR RSQ

Do not leave the person unattended Now What? Do not leave the person unattended Call County Crisis Line or 800.273.TALK Clackamas 503.655.8585 Multnomah 503.988.4888 Washington 503291.9111 Arrange for transport to the nearest available hospital for evaluation “Safety contracts” don't prevent suicide http://store.samhsa.gov/shin/content//SVP06-0153/SVP06-0153.pdf

Legal – ORS 426.231 (1) A physician licensed by the Oregon Medical Board may hold a person for transportation to a treatment facility for up to 12 hours in a health care facility licensed under ORS chapter 441 and approved by the Oregon Health Authority if: (a) The physician believes the person is dangerous to self or to any other person and is in need of emergency care or treatment for mental illness; (b) The physician is not related to the person by blood or marriage; and (c) An admitting physician at the receiving facility consents to the transporting. http://www.oregonlaws.org/ors/426.231

Legal, Part II – ORS 426.231, Continued (2) Before transporting the person, the physician shall prepare a written statement that: (a) The physician has examined the person within the preceding 12 hours; (b) An admitting physician at the receiving facility has consented to the transporting of the person for examination and admission if appropriate; and (c) The physician believes the person is dangerous to self or to any other person and is in need of emergency care or treatment for mental illness. (3) The written statement required by subsection (2) of this section authorizes a peace officer, an individual authorized under ORS 426.233 (Authority of community mental health program director and of other individuals) or the designee of a community mental health program director to transport a person to the treatment facility indicated on the statement. [1993 c.484 §3; 1997 c.531 §3; 2009 c.595 §403; 2013 c.360 §39] http://www.oregonlaws.org/ors/426.231

Suicide rates are increasing Most people with SI do not die by suicide Summary Suicide rates are increasing Most people with SI do not die by suicide The best get it right only 70% of the time Best strategy is to be gentle and direct, AND use an established screening tool such as SAFE-T Call for help! Be sure to document your rationale Stick around for SKA2 blood test?

Assessing Bipolar Disorder in the Primary Care Setting The End! Next Week's Topic: Assessing Bipolar Disorder in the Primary Care Setting 17