Suicide Risk and Violence Threat Assessment Developed by DATA of Rhode Island through a grant from the RI Department of Human Services through a grant from the RI Department of Human Services

Part 1:Suicide Assessment GOALS Participants to increase knowledge of suicide risk factorsParticipants to increase knowledge of suicide risk factors To understand which risk factors should most of concernTo understand which risk factors should most of concern To understand when and how the worker should intervene?To understand when and how the worker should intervene?

SUICIDE PREDICTION vs. SUICIDE ASSESSMENT Suicide Prediction refers to the foretelling of whether suicide will or will not occur at some future time, based on the presence or absence of a specific number of defined factors. Suicide (risk) Assessment refers to the establishment of a judgment of risk in the very near future, based on the weighing of information that is available. In general it is always better to err on the side of caution

COMPONENTS OF SUICIDE ASSESSMENT Survey and identify client risk factors and protective factors Elicit direct client communication about suicide Review previous History

SUICIDE: Contributing Factors Neurobiology Severe Medical Illness Impulsiveness Access To Weapons Hopelessness Life Stressors Family History Suicidal Behavior Personality Disorder/Traits Psychiatric Illness Co-morbidity Psychodynamics/ Psychological Vulnerability Substance Use/Abuse Suicide

Areas to Evaluate in Suicide Assessment PsychiatricIllnesses Comorbidity, Affective Disorders, Alcohol / Substance Abuse, Schizophrenia, Cluster B Personality disorders. History Prior suicide attempts, aborted attempts or self harm; Medical diagnoses, Family history of suicide / attempts / mental illness Individual strengths / vulnerabilities Coping skills; personality traits; past responses to stress; capacity for reality testing; tolerance of psychological pain Psychosocial situation Acute and chronic stressors; changes in status; quality of support; religious beliefs Suicidality and Symptoms Past and present suicidal ideation, plans, behaviors, intent; methods; hopelessness, anhedonia, anxiety symptoms; reasons for living; associated substance use; homicidal ideation Adapted from APA guidelines for suicide assessment

RISK FACTORSDemographic male; widowed, divorced, single; increases with age; white Psychosocial lack of social support; unemployment; drop in socio- economic status; firearm access Psychiatric psychiatric diagnosis; comorbidity Physical Illness Cancer; HIV/AIDS; systemic lupus; pain syndromes; functional impairment; diseases of CNS Psychological Dimensions hopelessness; pain/anxiety; psychological turmoil; low 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

PROTECTIVE FACTORS  Children or family in the home  Pregnancy  Deterrent religious beliefs  Life satisfaction  Reality testing ability  Positive coping skills  Positive social support  Positive therapeutic relationship

SUICIDE RISKS by SPECIFIC DISORDERS Higher Risk Groups Prior suicide attemptor (highest risk) Bipolar disorder Major depression Mixed drug abuse Personality disorders Alcohol abuse Cancer Chronic Pain Syndrome

COMORBIDITY In general, the more diagnoses present, the higher the risk of suicide. 50% had multiple Axis I and at least one Axis III diagnosis (medical problems) 44% had 2 or more Axis I diagnoses 31% had Axis I and Axis II diagnoses Only 12 % had a single Axis I diagnosis with no comorbidity

AFFECTIVE DISORDERS AND SUICIDE Highest Risk Profile: Elevated anxiety or panic symptoms alcohol abuse or dependence Prior suicidality Previous Hospitalization for affective disorder and/or suicidality Risk for men is four times as high as for women except in bipolar disorder where women are equally at risk Persisting Medical Condition

SCHIZOPHRENIA AND SUICIDE High-Risk Profile:  Previous suicide attempt(s)  Significant depressive symptoms - hopelessness  Male gender  First decade of illness – (however, rate remains elevated throughout lifetime)  Poor premorbid functioning  Current substance abuse  Poor current work and social functioning  Recent hospital discharge

 Suicide occurs later in the course of the illness with communications of suicidal intent lasting several years  In completed suicides, men have higher rates of alcohol abuse, women have higher rates of drug abuse  Increased number of substances used, rather than the type of substance appears to be important  Comorbid psychiatric disorders, females have Borderline Personality Disorder High Risk Profile:  Recent or impending interpersonal loss  Comorbid depression ALCOHOL / SUBSTANCE ABUSE AND SUICIDE

PERSONALITY DISORDERS AND SUICIDE Borderline Personality Disorder  Lifetime rate of suicide - 8.5%  With alcohol problems -19%  With alcohol problems and major affective disorder - 38%  A comorbid condition in over 30% of the suicides.  Nearly 75% of patients with borderline personality disorder have made at least one suicide attempt in their lives.

GENETICS FACTORS  Suicide appears to be an independent, inheritable risk factor.  Relatives of suicidal subjects have a four-fold increased risk compared to relatives of non- suicidal subjects.  Higher concordance of suicidal behavior between identical rather than fraternal twins.  Adoption studies: a greater risk of suicide among biologic rather than adoptive relatives.

 Family history of abuse, violence, or other self- destructive behaviors place individuals at increased risk for suicidal behaviors  Histories of childhood physical abuse and sexual abuse, as well as parental neglect and separations, are correlated with a variety of self- destructive behaviors in adulthood FAMILY PSYCHOPATHOLOGY

PSYCHOSOCIAL SITUATION: LIFE STRESSORS  Recent severe, stressful life events can be associated with suicide in vulnerable individuals  Stressors include interpersonal loss or conflict, economic problems, legal problems  High risk stressor: humiliating events, e.g., financial ruin associated with scandal, being arrested or being fired can lead to impulsive suicide.  Identify stressor in context of personality strength, vulnerabilities, illness, and support system.

 Firearms account for 55-60% of suicides (Baker 1984, Sloan 1990).  Firearms at home increase risk Guns are twice as likely to be found in the homes of suicide victims as in the homes of attempters Guns are twice as likely to be found in the homes of suicide victims as in the homes of attempters Type of gun (handgun, rifle, etc.) was not statistically correlated with increased risk for suicide Type of gun (handgun, rifle, etc.) was not statistically correlated with increased risk for suicide Risk management point: Inquire about firearms Document question and response. PSYCHOSOCIAL SITUATION: FIREARMS AND SUICIDE

PSYCHOLOGICAL VULNERABILITIES  Capacity to manage powerful feelings  Ability to tolerate aloneness.  Ability to experience and tolerate psychological pain  Features of ambivalence.  Tunnel vision/reversibility  Capacity for intimate relationships.  Ability to use external resources of support

COMPONENTS OF SUICIDAL IDEATION  Intent: Expectation and desire for a self- destructive act to end in death.  Lethality: Objective danger to life associated with a suicide method or action.  Degree of ambivalence - wish to live, wish to die  Intensity, frequency  Rehearsal/availability of method  Presence/absence of suicide note  Deterrents (e.g. family, religion, positive therapeutic relationship, positive support system - including work)

CHARACTERISTICS OF A SUICIDE PLAN Risk / Rescue Issues:  Method  Time  Place  Available means  Arranging sequence of events

PSYCHIATRIC SYMPTOMS MOST ASSOCIATED WITH SUICIDE Hopelessness/Depression Impulsivity / Aggression Anxiety Command hallucinations

PSYCHIATRIC SYMPTOMATOLOGY: HOPELESSNESS/Depression There is relationship between hopelessness and suicidal intent Subjective hopelessness is associated with fewer reasons for living and increased risk for suicide Hopelessness is changeable through various interventions

IMPULSIVITY / AGGRESSION contributes to suicidal behavior It is important to assess level of impulsiveness when assessing for suicidality and threat to others Suicide attempters may be more likely to present traits of impulsiveness / aggression regardless of psychiatric diagnosis Equally Important in assessing risk of murder-suicide

ANXIETY Anxiety symptoms (independent of an anxiety disorder) associated with suicide risk:  Panic Attacks  Severe Psychic Anxiety (subjective anxiety)  Anxious Ruminations  Agitation In a review of inpatient suicides 79% met criteria for severe or extreme anxiety or agitation

COMMAND HALLUCINATIONS  Patients with command hallucinations may not be at greater risk, per se, than other severely psychotic patients.  However, the majority of patients with suicidal command hallucinations should be considered seriously suicidal

DIRECT QUESTIONING ABOUT SUICIDE: Don’t be afraid to ask direct questions. Normalizing techniques help initiate the conversation Example: Worker: “People who have experienced losses and who are depressed, sometimes think that maybe life is no longer worth living. Have you ever felt that way? If the client answers positively to suicidal thoughts, ask more specific questions

COMPONENTS OF SUICIDE ASSESSMENT Revisited Survey and identify client risk factors and protective factors Elicit direct client communication about suicide Review previous history for suicide and other risk factors

DETERMINING OF THE LEVEL OF RISK Evidence of suicidal ideation always deserves a response. In determining risk level:  Previous suicidal history  The more immediate the plan, the higher the risk  The more impaired (MH or alcohol), the higher the risk  Access to means  Remember, suicide risk will need to be reassessed at various points over time, as a patient’s risk level will wax and wane.

DETERMINE A RESPONSE SET A PLAN  Always attend to issue of patient’s safety first.  Consult others  Consult PCH or Mental Health Provider  In situations of potential imminent danger, confidentiality is waived  Don’t rely on clients to follow through  If all else fails, call 911  Document, document, document

 Observable Symptoms  Any suicidal behavior or ideation.  Actual statements made by client  Known Risk Factors  The issue of firearms: If present - document If absent - document as pertinent negative (no guns in house)  Actions Taken by You With whom, when and outcome Any follow up What to Document

WHAT TO DOCUMENT IN A SUICIDE ASSESSMENT  Document: The risk level The basis for the determining risk level The plan for intervention…calling CMHC or Police; contacting supervisor Example: This 62 y.o., recently widowed man is experiencing his 2nd episode of major depressive disorder. In spite of his denial of current suicidal ideation, he is at moderate to high risk for suicide, because of a serious suicide attempt in the past, his continued depression, anxiety and hopelessness; recent loss and social isolation. The immediate plan is to contact the area CMHC and the clients primary care physician to advise of concerns.

WHEN A SUICIDE OCCURS Despite best our efforts suicides can and do occur Approximately, 12,000-14,000 suicides per year. To facilitate the aftercare process:  Ensure that the client records are complete  Be available to assist grieving family members  Remember document all activities and interventions  Seek support from colleagues / supervisors  Consult risk managers if available

Questions