Suicide Risk Assessment and Risk Management Training

Suicide Risk Assessment and Risk Management Training
(QPRT) Presented by: Paul LeBuffe & Susan Kiesling ICTR The Devereux Foundation Add your name in place of Susan’s and mine. If you have any questions on any of this content, please me at or call me at (610) Last Updated 05/29/2009

QPRT Schedule 8:30 - 8:45 Introductions & Overview of the Day
8: :00 Devereux’s Suicide Risk Reduction Program The Magnitude of Suicide Problems in the United States 9:00 – 10:30 Overview of Suicide Risk and Protective Factors 10: :45 BREAK 10: :00 Suicide and Malpractice 12: :45 LUNCH 12: :15 Approaches to Suicide Risk Assessment 1: :15 Overview of the QPRT 2: :30 BREAK 2: :15 QPRT Practice Exercise 3: :35 Re-Evaluation and Pass/Discharge MR/DD Guidelines 3: :00 Management of the Suicidal Client 4: :30 Final Discussion, Posttest, and Evaluation

Devereux’s Suicide Risk Management Program
Three Goals: Reduce the incidence of suicide spectrum behavior among Devereux clients To protect Devereux and Devereux staff from unnecessary lawsuits To provide, as much as possible, peace of mind to Devereux staff should we have a client complete suicide Devereux began its suicide risk management program in 1999 at the request of the Board of Trustees. We have received national recognition as being a leader in this area. We were the first nationwide behavioral healthcare provider to undertake such an effort. RE this slide – #1 is, of course the most important. It reflects our duty of beneficence to our clients. #2 – stress that this is not just a defensive “cover our ass” position, but that Devereux operates on a very slim financial margin and that any monies that we spend on malpractice settlements takes funds away from program. This reflects our duty to protect Devereux assets. #3 – Stress that there is nothing that we can do or say that can guarantee that we will not have another suicide at Devereux. However, if and when we do, we want the clinician to know that he/she did everything they reasonably could be expected to do to avoid that outcome. The Devereux program exceeds the community standard of care.

Devereux’s Suicide Risk Management Program
Why? There is a high incidence of suicide following hospitalization, particularly within the first three months. (Roy, 1986) Four Objectives: Every Devereux staff completes a 60-minute suicide awareness and prevention program (QPR) Every Devereux clinician completes a full-day suicide risk assessment program (QPRT) Every Devereux client is assessed for suicide risk at: Admission Midtreatment, or when there are significant changes in risk factors, protective factors or level of care. Discharge Every Devereux center has a suicide-specific crisis response plan. Why? 1/3 of suicides occur in the hospital 1/3 of suicides occur on authorized pass 1/3 of suicides occur on unauthorized pass (Farberow, 1994: Litman, 1982) Why? Suicidal ideation/behavior is the most common reason for psychiatric admissions . (Friedman, 1989) Approximately 17% of all suicides are completed in treatment. (Busch et al., 1993: Litman, 1982) Self-explanatory. Stress that clinicians should also attend QPR. It is important for them to understand what we are instructing other staff to do. QPRT is not a replacement for QPR. Note: Approximately 17% of all suicides are completed in treatment = about 5000 suicides a year in treatment Approximately 1,500 inpatient suicides occur with about a third of these occurring while patients are on one-to-one (American Psychiatric Association 2003)

JCAHO New Inpatient Care Standards
As of January 2007, every JCAHO accredited behavioral health care organization must have a formal process in place for assessing and managing suicide risk. At Devereux, we were ahead of the curve. We have had these procedures in place for over seven years. Self-explanatory

The Magnitude of the Suicide Problem in the United States
It is important that Devereux clinicians recognize that suicide is not just an issue for Devereux, but is a national problem. We begin with an overview of suicide in the nation as a whole to provide a context for our discussion of suicide prevention within Devereux.

Suicide rates are the basic unit of measurement in suicidology
Suicide rates are the basic unit of measurement in suicidology. The rate = the number of deaths due to suicide per 100,000 individuals in the population per year. For example if the population was 1 million and the suicide rate was 10, that would mean that 100 people would die from suicide each year in that population. These numbers are thought to be a underestimate of the true number of suicides. Coroners will categorize a questionable death as an accident unless there is clear evidence that it was a suicide. There are at least two reasons for this: 1) most insurance policies will not pay out if the death was self-inflicted, and 2) to spare the family the shame and stigma that is associated with a suicidal death. Key points for this slide. 1) the rate in the elderly has decreased more than 50% in the past 60 years. 2) However, the rate for youth has tripled since the 1950s, 3) these trends cancel each other resulting in a pretty stable rate of suicide throughout the past years. In the late 1990s and early 2000s, the rate for youth began to drop, but in the past year for which data is available (2004) the rate began to climb again. McKeown, Cuff, Schulz (2006)

American Numbers: 2006 Data
33,300 completed suicides in 2006 Rate: 11.1 per 100,000 91 per day (equivalent of one commercial jet every other day) One person every 15.8 minutes Suicide does not respect age, race, religion, social or economic status; it’s an equal opportunity mode of death. These are ways of putting the rate/number into a more meaningful context. A couple of other ways: 1) in the 9/11 tragedy we lost about 3,000 lives. We lose that many to suicide nearly every month, year after year; 2) in the entire Vietnam war we lost about 50,000 service men and women. We lose that many to suicide every two years. Re the last point, although there are differences in rate among different groups, there is no group that is exempt from suicide. Cdc.gov

Suicide is a leading cause of death
Rank & Cause Number of deaths 1. Diseases of the heart ,636 2. Malignant neoplasms ,888 3. Cerebrovascular diseases ,119 4. Chronic lower respiratory disease ,583 5. Accidents ,599 6. Diabetes mellitus ,449 7. Alzheimer’s disease ,432 8. Influenza & pneumonia ,326 9. Nephritis, nephrosis ,344 10. Septicemia ,234 11. Suicide ,300 Ranking 11th in the USA (CDC 2006 Data)

Suicide vs. Homicide Suicide is the 11th leading cause of death with 33,300 deaths Homicide is the 15th with 18,124 Why don’t we hear more about suicide in the media? Each year, for over a century, we lose more lives to suicide than homicide. Approximately 50% more – most people will find this startling. Why don’t we hear more about all of these suicides? There are guidelines for the media that stress not publicizing suicides because it will increase the likelihood of other suicides by individuals that are already at risk (ie suicide receptive). (CDC 2005 Data)

Youth Suicide: CDC 2007 Data
For youth ages 10 to 24: Suicide is the 3rd leading cause of death and accounts for 12% of youth deaths There are 4600 lives lost each year Each year, about 142,000 youth receive medical care for self-inflicted injuries 82% of the deaths were males and 18% were females, still females are more likely to report attempting suicide than boys cdc.gov

Youth Suicide: CDC 2007 Data
A nationwide survey of youth in grades 9-12 found that in the 12 months preceding the survey: 15% of students reported seriously considering suicide 11% reported creating a plan 7% reported trying to take their own life 2% received treatment for self-inflicted injuries cdc.gov/healthyyouth/yrbs/pdf/yrbss07_mmwr.pdf

Suicide Attempt “ Any potentially self-injurious action, with a nonfatal outcome, for which there is evidence, either explicit or implicit, that the individual intended to kill himself or herself.” Carol, Berman, Maris, et. al., Journal of Suicide and Life-Threatening Behavior, 1996.

Estimates on attempted suicide
25 attempts for each documented death (Note: 31,000 suicides translates into 775,000 attempts annually)

Suicide Attempts Most don’t die in their attempt
Children: attempts per 1 completion Elder: 4 attempts per 1 completion Average: 25 attempts per 1 completion Children have so many attempts/per completion because they do not have much practical knowledge about what it takes to kill oneself. Elders, on the other hand, have lots of practical knowledge and therefore fewer attempts. In addition, whereas children and youth might use suicide as a “cry for help,” most elderly do not. If a suicide attempt in an older person fails, it is probably because the means wasn’t lethal, not because they didn’t intend to die. (CDC 2006 Data)

Number of suicide survivors
It is estimated that there are 6 survivors for each death by suicide Note: A “suicide survivor” is someone who has lost a loved one to death by suicide 1 of every 65 Americans is estimated to be a suicide survivor In Susan and my experiences, there seem to be far more survivors than this. We have not conducted a training in the past few years without there being at least one survivor in the audience. Stress that most communities have suicide survivor support groups. You should have the contact information for your local group.

BASIC CONCEPTS ABOUT SUICIDE
Suicide is always multi-determined. Suicide prevention must involve multiple approaches. Most suicidal people do not want to die. Suicidal people want to find a way to live. Ambivalence exists until the moment of death. The final decision rests with the individual. Reduce risk factors and you reduce risk. Enhance protective factors and you reduce risk. RE the first point, press coverage and the usually belief of the “common man” is that people complete suicide because of a single crisis such as a breakup, being fired or laid-off, or losing the state football championship. However, when a psychological autopsy is conducted by trained professionals, nearly universally, other pre-existing risk factors are uncovered. Common ones include mental illness, substance abuse, history of interpersonal conflict. The “crisis” might be the final straw or trigger that pushes the person over the edge, but it always occurs in the context of other risk factors. RE points three, four and five – see, for example, Richard Sidon’s work on attempters on the Golden Gate Bridge. See also the “Bridge Story” in QPR training. Re point six – please emphasize that there is nothing in QPRT or any other training that guarantees that no one will complete suicide. Ultimately, the decision is made by the suicidal individual. We can reduce and manage risk, and reduce the probability of suicide, but we can’t, in any absolute sense, prevent it all of the time. Please also stress the need to increase protective factors. This is consistent with the Philosophy of Care (positive approaches), is consistent with best practice and is often under-emphasized in our treatment plans.

Suicide Risk & Protective Factors
If folks are unfamiliar with these terms: A risk factor is a process, event or characteristic that leads to a worse developmental outcome in a group of people. A protective factor is a process, event or characteristic that protects the individual from risk (or buffers the individual from risk, or decreases the impact of a risk factor) and thereby leads to a better developmental outcome than would have been expected in its absence.

The Many Paths to Suicide
Risk Factors Triggers Means Demographic Poison Expelled Arrested Age Sex Gun Race Geog-raphy Fired Sexual Orientation Hanging Personal History Increasing Hopelessness Contemplation of Suicide as Solution Culture Shock/ Shift Model for Suicide Com-mitted WALL OF RESISTANCE Values Beliefs Religion Child Abuse ? Autocide At the beginning, you might want to stress that none of these factors is pathognomic or specific to suicide (that is increases risk only for suicide and not other problems). In general, the more of these you observe, the higher the risk. This slide presents a model for organizing our thinking about suicide. Time moves from left to right on this slide. That is, we begin with risk factors, then move to triggers, increasing hopelessness, the wall of resistance, and finally end at the suicidal act. Jumping Psychological Status Major Loss ? Substance Use ? Personality Traits ? Divorced Diagnosis

Demographic Risk Factors: Age
Adults aged comprise the largest number of suicides Elderly White males have the highest rates of suicide For males, after age 65 their risk for suicide increases exponentially For women, risk of suicide peaks during young adult and middle aged years Old white males are the highest risk group: 71.4% use a firearm (lethal planners) They know how to do it and plan carefully They avoid rescue. For men, retirement and the loss of their identity as bread winner, etc. may increase risk For women, the age of increased risk (middle age) is thought to be influenced by the empty nest syndrome and menopause.

Risk Factors Triggers Means Demographic Poison Expelled Arrested Age Sex Gun Race Geog-raphy Fired Sexual Orientation Hanging Personal History Increasing Hopelessness Contemplation of Suicide as Solution Culture Shock/ Shift Model for Suicide Com-mitted WALL OF RESISTANCE Values Beliefs Religion Child Abuse ? Autocide Jumping Psychological Status Major Loss ? Substance Use ? Personality Traits ? Divorced Diagnosis

Demographic Risk Factors: Sex
Females attempt suicide more than males at a ratio of 3:1 Males complete suicide more than females at a rate of 4:1 However, in mental health treatment programs, females are just as likely to complete suicide as males “If a man calls, take him seriously” Men of all ages are in high risk groups “If a woman calls about a man, take her even more seriously.” The inset box is a key message – at Devereux, our female clients are as likely to attempt or complete as their male counterparts. (CDC 2006 Data)

Demographic Risk Factors: Race
When considering all age groups and both sexes, Whites and Native Americans have the highest suicide rates (11-14 per 100,000) The rates of suicide among Indians and Alaska Natives are about 1.7 times higher than the national average. It is thought that this is due to familial disruption, cultural conflict, and social disorganization. Asian-Pacific Islanders, African-Americans, and Hispanics have rates at approximately half that of Whites and Native Americans ( per 100,000). One interesting exception to this, which you do not have to mention, is that among college and graduate students, Asian-Americans have relatively high rates of suicide. 2006 DATA: Whites: 12.4 Nation: 11.1 Nonwhite: 5.5 White rates are nearly twice those of nonwhites as a whole

Epidemic of Suicide among African American Male Youth
The rate has increased 200% since the mid-1970s Rates are now approximating that of their white age/gender peers Nearly all of the increase is in urban areas and involves guns Lay My Burden Down by Poussaint and Alexander Re point 2: This increase has been attributed to acculturation effects as well as to the idea that black youths often feel that society has no place for them, similar to the hypothesis behind elderly suicide (Goldsmith et. al., 2002)

Demographic Risk Factors: Geography Regional differences in U.S. rates
15.8 6.8 – 8.6 You should look up your center’s state’s ranking. AAS’s website, suicidology.org, has this info. Why do these differences exist? Some factors include 1) higher rates of alcoholism and gun ownership in rural, western areas. 2) less positive attitudes towards mental health services in the rural west (vs. e.g. New York City), 3) less access to mental health services and emergency medical services in rural areas. Suicide is highest in the Mountain States

Demographic Risk Factors: Sexual Orientation
There is an elevated risk of suicide attempts among GLB people, particularly GLB youth GLB youth who use alcohol or drugs as means of escape from persecution and doubt over an emerging gay or lesbian identity have elevated profiles for suicidal risk compared with other GLB youth Why is there an elevated risk in GLB people (especially youth)? Climate of homophobic persecution in schools and sometimes in family and community Values and actions that stigmatize homosexuality The youth who has not yet “come out” has to conceal large part of identity May have limited social support Re Point 1: gay, lesbian, and bisexual adolescents (males in particular) can have rates of serious suicide attempts at least four times those of apparently heterosexual youth Emphasize that GLBTQ is not, by itself, a risk factor. Increased risk is a result of the social/interpersonal issues noted in the inset box. Sources: Bagley & Tremblay, 2000; McDaniel, Purcell & D'Augelli 2001; D'Augelli, Hershberger & Pilkington, 2001

Personal History: Child Abuse
Childhood trauma, specifically childhood sexual abuse, is a strong risk factor for suicide. Adults with a past history of abuse are up to 25 times more likely to attempt suicide than their non-abused counterparts. Even after controlling for psychopathology and other known risk factors, child sexual abuse accounts for 9-20% of suicide attempts in adults (Goldsmith, et.al., 2002). Self-explanatory

Personal History: Culture Shock
Recent Immigrants Suicide rates for recent immigrants generally reflect the rates of their countries of origin. Suicidality among recent immigrants can be attributed to acculturation stress, which includes: However, immigrants may also have increased protective factors, such as spiritual beliefs, increased social support, and stable marital status Re Bullet Point 2: includes disrupted social support and family support networks Low education and income lack of knowledge about the language and culture of the host country lack of tolerance towards immigrants from host country

Personal Model for Suicide
Suicidality and suicide risk runs in families Twin studies and adoption studies have shown that there are genetic contributions to alcoholism and major mood disorders, both of which are associated with increased suicide risk (Colt, 1991) Repeat attempters have a higher presence of suicidal behaviors in their family history (AAS, 2004) Suicide risk is greater in survivors of suicide (e.g. 4-fold increase in children when a parent dies by suicide) However, in the acute period immediately following a family member’s suicide, the risk for survivors actually significantly decreases. This is because of the increased levels of social support that occur during a mourning period. Social support is a very powerful protective factor. For an interesting example of this, look up the Hemingway family tree.

Personal History: Model for Suicide
Clustering of Suicide Clusters occur when two or more completed or attempted suicides are non-randomly “bunched” in space or time Reports of suicide in the media may make already suicidally inclined more likely to complete We used to use the term “suicide contagion.” Current thinking stresses the term clusters. “Contagion” implies that suicidality is infectious and otherwise non-suicidal people can “catch” suicidality from a completer. That is the suicide of one individual puts the thought in other’s heads. More correctly, a suicide in a community both increases stress as well as serves as a model for individuals that are already thinking of suicide and thereby might make another suicide(s) more likely leading to a cluster. Our crisis response plans detail the actions that we need to take to reduce the probability of a suicide cluster.

Risk Factors Triggers Means Demographic Poison Expelled Arrested Age Sex Gun Race Geog-raphy Fired Sexual Orientation Hanging Personal History Increasing Hopelessness Contemplation of Suicide as Solution Culture Shock/ Shift Model for Suicide Com-mitted WALL OF RESISTANCE Child Abuse Values & Beliefs ? Autocide Jumping Psychological Status Major Loss ? Substance Use ? Personality Traits ? Divorced Diagnosis

Personal History: Values, Beliefs & Cults
Suicide by Cop Heaven’s Gate Can you envision a time when suicide may be acceptable? Self-explanatory. Source: Goldsmith, et.al., 2002

Personal History: Values, Beliefs & Cults
Cultural Values Suicide is morally acceptable in some cultures in specific circumstances Among Buddhists, self-sacrifice for religious reasons is viewed as honorable Chinese women with no children can demonstrate their faithfulness to their husbands by completing suicide if their husband dies. Greater social stigma against suicide can be a protective factor The Hindu code of conduct condones suicide in the instance of incurable diseases or great misfortune In India, it was once acceptable and often expected that a woman burn herself to death on her husband’s funeral pyre Suicide is an acceptable response to disgrace in Japan. Historically, it was expected that the individual completing suicide also kills his or her children rather than burden someone else with their care.

Mental Illness and Suicide
Facts: Over 90% of all people who die by suicide are suffering from a major psychiatric illness More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease COMBINED These deaths are due to untreated or under-treated brain disorders The first point is one of the most important, take-home messages in this entire training. The basic strategy of most suicide prevention and risk management programs is to identify individuals at risk for suicide and get them into effective treatment. Good treatment is what helps save lives.

Psychological Status: Diagnostic risk factors
Axis I Affective Disorders Alcoholism and/or Substance Abuse Schizophrenia Panic Disorders These are not the only disorders that increase risk of suicide, but these have the strongest associations. Axis II Borderline Personality Disorder Antisocial Personality Disorder

Axis III Axis IV Axis V Organic Affective Disorder Multiple Sclerosis
Respiratory Problems Chronic Pain AIDS (40% higher rate than the general population) Axis IV Increase in the quantity and severity of psychosocial stressors Narcissistic injury, shame or humiliation Impending or perceived interpersonal loss Axis V A marked change in GAF is probably more significant in relation to risk than the actual numerical rating

NEUROBIOLOGY OF SUICIDE
Familial patterns of suicide suggest biological factors may influence risk. Low HIAA has been found in severe suicidal depressions. A majority of studies have suggested reduced serotonin function in suicide, especially in suicides of high lethality or with considerable planning. Emerging evidence provides tantalizing, but not compelling evidence, that depletion of essential neurotransmitters, including dopamine and serotonin, may be the common clinical pathway for suicidal thinking, feeling and behaviors. Life history, culture, attitude and various forms of psychopathology, probably outweigh potential genetic determinants. You don’t need to stress this too much other than to note that there is clear evidence for a biological component to suicide risk. From Joseph Coyle, MD, Harvard Medical School, 1997

BIPOLAR DISORDER & SUICIDE
#1 cause of death, 1-2% of individual with BPD die per year. Lifetime deaths from suicide - 30 studies 9-46% x = 19%. Attempts Bipolar Disorder = 25%-50% Major Depressive Disorder = 20% General Population = 1% Highest risk windows Early in illness In denial phase During mixed states Lithium has pronounced anti-suicide effect. Lithium appears to decrease aggression and impulsivity. Psychotherapy and mood stabilizers prevent suicide better than mood stabilizers alone. K. R. Jamison, 1997 John Hopkins University For this and other slides, the lifetime risk is for individuals that are not in effective treatment. Once in effective treatment, the rates drop dramatically. However, in the nation, less than half of individuals with mental illness ever even seek treatment. Of those that receive treatment, much of it is ineffective. Hence the emphasis on evidence-based practices.

MDD AND SUICIDE 7-15 % die by suicide.
98 % of completed suicides are seriously depressed (aggressive rx is indicated). Most suicide attempts take place when person is off antidepressant medication. Compliance/adherence is essential to safety. For severe, agitated and suicidal depressions, electrocon- vulsive therapy may be the best choice. Patient education: death is a possible result of discontinuing medications. Benzodiazapines are often under used in anxious/ agitated suicidal depressions. Self-explanatory % Die by suicide is variable depending on setting in which that individual with MDD resides.

Short-term Risk Indicators For Depression and Suicide
Severe psychic anxiety Extreme hopelessness or lack of pleasure in life Insomnia Diminished concentration Indecisiveness Acute overuse of alcohol or other drugs Panic attacks Obsessive-compulsive features Current episode of cycling affective illness 1-3 past episodes of depression Absence of children in the home Current absence of friendships and/or support Note that much of these refer to “perturbation,” the term for restless, severe, anxiety. Stress that many individuals who complete suicide were very anxious, agitated, upset, etc. in the hours previous to the attempt/completion. Signs of “perturbation” are key risk factors.

SUICIDE AND SCHIZOPHRENIA
M.T. Tsuang, MD, Harvard Medical School, 1998 Twenty to 40% make a suicide attempt. Ten to 15% complete suicide. High-risk years: ages 15 to 40 Clozapine responders often realize they have lost 20 to 30 years of life, resulting in acute depression, despair and elevated suicide risk. Negative symptoms for schizophrenia lead to hopelessness and increased risk. Suicide occurs during active phases of the illness. Suicides occur after discharge and in the first year of follow-up from index illness. Major risk factors: young age, early stage of illness, substance abuse present, college education, multiple episodes of psychosis, living alone, history of previous attempt. Improving on medications is the most dangerous time. RE major risk factors (2nd from end) one explanation is that college educated individuals are better at finding information on this disorder (via the web, etc.) and because prognosis is not good, may be more likely to lose hope. Only 4% do so in response to a “voice” in their head

Borderline Personality Disorder and Suicide
5-7% will die by suicide. Past abuse history. Parasuicidal behaviors. The risk of completion is 12-15%, doubling the risk. We need to stress the very real possibility of suicide among our clients with BPD. They are at greatly increased risk – same as schizophrenia. The possibility of suicide is real. Always conduct a thorough risk assessment.

Implications for Prevention
Swedish Committee for Prevention and Treatment of Depression Gotland Island Study ( ) 2 session educational program on treating depression and recognizing suicide risk for 18 general practitioners serving the 56,000 inhabitants of the island of Gotland For 3 years before program, Gotland had same suicide rate as Sweden In the year after the program, the island’s suicide rate dropped to 29% of Sweden’s rate Aggressive, effective treatment saves lives – here’s one study that proves it! “Increased recognition of depression and knowledge about its treatment can have a substantial impact on the suicide rate.” Source: Rutz, et.al., 1989

Risk Factors Triggers Means Demographic Poison Expelled Arrested Age Age Sex Gun Race Geog-raphy Fired Sexual Orientation Hanging Personal History Increasing Hopelessness Contemplation of Suicide as Solution Culture Shock/ Shift Model for Suicide Com-mitted WALL OF RESISTANCE Values Beliefs Religion Child Abuse ? Autocide Jumping Psychological Status Major Loss ? Substance Use ? Personality Traits ? Divorced Diagnosis

Personality traits associated with suicide risk
Hostile and aggressive (Either externally or with themselves) Impulsive Interpersonal difficulties (Have often had a recent failure or conflict in a relationship) RE point one – there are clear links between interpersonal aggression/violence and suicide. Freud talked about suicide as “murder in the 180th degree”. Domestic violence, filicide, infanticide all have associations with suicide.

Rigid cognitive styles
Dependency (Upon relationships, chemicals or both) Rigid cognitive styles Tendency to see things as very “black or white” Either want a total solution or “totally out” Poor problem solving skills or application Low self-esteem Self-explanatory

Psychological Status:
Substance Use Lifetime risk for alcoholics: 2 - 3%. Fifteen percent to 25% of all suicides by alcoholics. Major risk factors: male, long-term drinker, comorbid psychiatric disorder. Highest risk group: depression and alcoholism. Links to suicide: poor judgment, impulsiveness, aggressiveness; loss of job, health, home, money. State variable (intoxication) associated with at least 50% of all suicides. Alcohol myopia. Alcohol myopia is the shortsightedness associated with alcoholism. That is, alcoholics to not engage in good, long-term planning and problem-solving. They are often preoccupied with their immediate situation and where the next drink is coming from.

When these three are present-the risk of violence is high.
THE LETHAL TRIAD UPSET PERSON This is straight from law-enforcement. If a police officer receives a domestic violence call and these three factors are present, he/she knows it is a dangerous situation. Same is true in mental health, just substitute mental illness for upset person. This is the most dangerous co-morbidity re suicide. Especially depression, drinking and guns. Good news is that we can intervene on all three points – mental health treatment, substance abuse treatment and means restriction. FIREARM ALCOHOL When these three are present-the risk of violence is high.

Other Substances Cocaine use is associated with an increased risk of suicide attempts but illicit use of marijuana and sedative-hypnotics (i.e. sleeping pills, tranquilizers, or general sedatives) is not. (Petronis, et.al., 1990) Opiate users have a suicide rate 4 times higher than that of other substance abusers (Goldsmith, et.al., 2002) Self-explanatory

Risk Factors Triggers Means Demographic Poison Expelled Arrested Age Sex Gun Race Geog-raphy Fired Sexual Orientation Hanging Personal History Increasing Hopelessness Contemplation of Suicide as Solution Culture Shock/ Shift Model for Suicide Com-mitted WALL OF RESISTANCE Values Beliefs Religion Child Abuse ? Autocide These are the events that can push an individual over the edge so that they begin to contemplate suicide. Again, they occur in the context of the risk factors that we previously discussed. You might ask what trigger events would occur in our client populations and programs. Jumping Psychological Status Major Loss ? Substance Use ? Personality Traits Others? Divorced Diagnosis

Triggers or “Last Straws”

Triggers/Last Straws Sudden sobriety and painful reality Discharge phenomenon Drug or alcohol relapse Loss of an idealized or important relationship Threat of loss Health issues or concerns The “unacceptable wound” Fear of becoming a burden to others Lifting of depression Suicide cluster effect Anything which may “wink out the last light of hope” Point 1 – some individuals, after becoming sober, realize what they have lost Point 2 – suicide risk is greatly increased in the 30 to 90 days post discharge. Gone from a protective, nurturing environment back to one that may be filled with risk factors. Point 3 – relapse is a key risk factor. Not only is it yet another failure experience, but now the person is drinking/abusing again with alcoholic myopia, etc. Rest self-explanatory

Risk Factors Triggers Means Demographic Poison Expelled Arrested Age Sex Gun Race Geog-raphy Fired Sexual Orientation Hanging Personal History Increasing Hopelessness Perturbation Contemplation of Suicide as Solution Culture Shock/ Shift Model for Suicide Com-mitted WALL OF RESISTANCE Values Beliefs Religion Child Abuse ? Autocide Note that suicide is contemplated as a solution to a seemingly insoluble problem. The individual is actively considering suicide because he/she sees no other possible way out of their situation. Jumping Psychological Status Major Loss ? Substance Use ? Personality Traits ? Divorced Diagnosis

Increasing Hopelessness
Hopelessness is the “final common pathway” The association between suicidality and hopelessness is stronger and more stable than the association of suicidality with depression and substance use disorders Point 2: In a longitudinal study of hopelessness, people who expressed hopelessness in 1981 were 11 times as likely to have completed suicide over the 13-year follow-up interval (Wen-Hung, Gallo, & Eaton, 2004).

WALL OF RESISTANCE TO SUICIDE PROTECTIVE FACTORS
RELIGION/SPIRITUAL (PROHIBITION) SOBRIETY BEST FRIENDS MEDICATION COMPLIANCE COUNSELOR/ THERAPIST DUTIES TO OTHERS PETS FEAR (PAIN, DISGRACE,ETC.) RESPONSIBILITY FOR CHILDREN JOB SECURITY JOB SKILLS GOOD HEALTH SAFETY AGREEMENT TREATMENT AVAILABILITY (HOPE) POSITIVE SELF-ESTEEM These are some key protective factors. The more “bricks in the wall’ the better. One risk assessment approach, developed by David Jobes at the Catholic University of America, is to ask the client how many reasons for living and reasons for dying he/she has. If the individual can’t list a few reasons for living, you’re in trouble. This wall includes many reasons for living. Consistent with the Philosophy of Care, one of our strategies is to identify, reinforce or develop as many protective factors as we can. Religion and religiosity are considered protective factors Organized religion provides a support system and social network Spirituality can be a coping resource Religious people are much less likely than non-religious people to abuse drugs and alcohol Many religious persons morally object to suicide Responsibility for one or more children is a powerful protective factor against suicide in women CALM AFFECTIVE ENVIRONMENT SUPPORTIVE SIGNIFICANT OTHERS DIFFICULT ACCESS TO MEANS ? ? ? ?

Indicators of Imminent Danger of Suicide
Severe psychic anxiety/turmoil Perturbation/Agitation Incessant rumination Global insomnia Delusions of gloom and doom Recent alcohol use (with or without alcoholism) Jan Fawcett, M.D., 1997 These are those short-term, high-risk indicators that sometimes precede suicide attempt by hours.

Risk Factors Triggers Means Demographic Poison Expelled Arrested Age Sex Gun Race Geog-raphy Fired Sexual Orientation Hanging Personal History Increasing Hopelessness Contemplation of Suicide as Solution Culture Shock/ Shift Model for Suicide Com-mitted WALL OF RESISTANCE Values Beliefs Religion Child Abuse ? Autocide If there aren’t enough “bricks in the wall” the individual may move on to make a suicide attempt or completion. Jumping Psychological Status Major Loss ? Substance Use ? Personality Traits ? Divorced Diagnosis

Methods of USA suicides
Firearms % Hanging % Solid and liquid poisons % All other methods % Autocide ??? Note – firearms are the most frequently used means for both sexes. Because of the nature of autocides data is inconclusive, but it is questioned if there are actually more autocides than suicides by firearm CDC (2006)

Considerations regarding methods/means
A gun in the home is 43 times more likely to be involved in the killing of a family member or friend than an intruder. Guns involved in a suicide attempt are fatal nearly 100% of the time (versus 5% by cutting and 23% by overdose.) To complete suicide by hanging, one does not have to be suspended. To complete suicide by jumping, one does not have to jump out of a multiple story building Re pts 3 and 4, we included these to stress that our clients can hang themselves even if we do not have exposed beams, etc. All they need to do is to tie something around their neck and around a fixed object (like a doorknob or pipe) and lean forward putting their weight on the noose. Similarly, one can jump off a one-story building, or even a tall piece of furniture and seriously hurt or even kill oneself.

Demographics of Inpatient Suicides
Gender: Equal Diagnoses: Depression and Schizophrenia Methods: 1) Hanging 2) Jumping Timing: At the beginning of hospitalization and towards the end. Re: point 1 – Once in treatment, males and females have an equal risk of dying from suicide. Re: point 3 – individuals in treatment programs do not have access to guns, knives or overdosing, so the most frequent means in an inpatient unit are hanging and jumping. Note that the timing in point four corresponds to two of the times (admission and discharge) when a QPRT is required. This is why. They are high-risk periods.

Questions? This is the end of this module. Complete Vignette Exercise.

Suicide Risk Assessment and Risk Management Training

Similar presentations

Presentation on theme: "Suicide Risk Assessment and Risk Management Training"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Suicide Risk Assessment and Risk Management Training

Similar presentations

Presentation on theme: "Suicide Risk Assessment and Risk Management Training"— Presentation transcript:

Similar presentations

About project

Feedback