1. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. The A B C & D’s of Suicide Assessment and Clinical Documentation This training is for educational purposes; the information was gathered from the American Psychiatric Association Clinical Practice Guidelines on Suicide and the Harvard Risk Management Task Force on Suicide

2. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Overview All organizations surveyed under either the Hospital or Behavioral Healthcare standards of the JCAHO will be required by January 1, 2007, to have a plan in place to assess patients at risk for suicide. Suicide is the #1 sentinel event reported to the JCAHO. For staff members working within the inpatient setting, there is heightened need to be able to effectively assess, monitor and treat suicidal individuals while they are in 24 hour treatment and as they make the transition to home and the community. We know that, as clinicians, you strive to provide the best quality of care to those individuals that you serve and assure their well being and safety. Therefore understanding the key elements of lethality and risk assessments and the necessary and appropriate documentation is imperative to meet your goals for exemplary patient care.

3. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Objectives Understand risk factors associated with suicide Identify 3 areas of current professional focus relative to suicide assessment Describe assessment approaches contained in the APA Practice Guidelines for the “Assessment and Treatment of Patients with Suicide Behaviors” and how Kaleida Behavioral Health adopted the best practice approach in its lethality assessment Identify items that are included in a suicide assessment protocol and how it will be documented in the patient’s medical record

4. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide Statistics in the United States Part 1 Source: National Institute of Mental Health Data: Centers for Disease Control & Prevention. National Center for Health Statistics, 2002 – 2005.

5. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. United States Demographics & Statistics Suicide rate: 12/100,000 Total Deaths: 30,862 Average rate: 85/day One person dies from suicide in the US every 18 minutes Third leading cause of death for college students Ninth leading cause of death overall 5 th in ages 5-14 years 5 th in ages 25-44 years 4 th in ages 65-85 years

6. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. United States Demographics & Statistics

7. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide & Mental Disorders More than 90% of suicides are associated with mental or addictive disorders Mood Disorders Substance Abuse Schizophrenia Panic Disorder Personality Disorder

8. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide & Mood Disorders 11 million persons in the US suffer depression each year, yet fewer than 1/3 seek treatment Depression is the diagnosis most often associated with suicide (40-80%) Rate of suicidal ideation in depressed patients is 19%-90% Annual rate of suicide attempts among depressed individuals is 3.65%

9. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide & Mood Disorders 15% lifetime risk of suicide Risk is increased by: Comorbid substance abuse Anxiety/Panic Attacks Anhedonia Hopelessness Suicidal Ideation History of family member, self attempting or committing suicide

10. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide & Schizophrenia Ideations in 60-80% of patients Attempts in 30-55% of patients 10% lifetime risk Risk increased by: Good premorbid functioning Early phase of illness Recognition of deterioration Hopelessness/depression as a symptom to affective change

11. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide & Substance Abuse 3% lifetime risk Alcohol/drug abusers: 15-25% of suicides Intoxication found in half of youthful suicides Risk increased by: Active substance abuse Adolescence or Illness in the 2 nd /3 rd decade Comorbid psychiatric illness Recent or anticipated interpersonal loss

12. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide & Panic Disorder 7-15% lifetime risk Independent or secondary to comorbid disorders Not only during attacks Risk increased by: Demoralization Loss Agitation

13. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide & Personality Disorder 7% lifetime risk Risk increased by: Comorbid mood disorder or substance abuse Impulsivity Hopelessness/despair Antisocial features Self-mutilation Psychosis

14. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide & Age Youth and Elderly rates remain highest (2002) Rate in 15-24 years old was 13.5/100,000 Third leading cause of death in males 15-24 Rate in 65+ years old was 18.06/100,000 Rate in <5 years on age increased

15. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide, Gender & Race Sex: 4.5 times as many males (2005) Gender Orientation: increased risk among gay youth Race: (2005 data): More than 70% of US suicides are white males Highest rates in American Indian and Alaskan Natives Latino, Native American, African American suicides significantly increased since 1999 Black youth (10-19) rate especially increasing

16. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide & Adolescence: Special Concerns that Increase Suicide Risk Separating from families Making new social connections Solidifying identity, finding role Need for rapid maturation of social skills Drugs, Alcohol availability Competition and self –image Onset of severe mental disorders Increasing rates in non white youth suicide

17. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide & Clusters Definition: 3 or more linked events Imitation effect is most clear with: Copier is adolescent Pre-existing vulnerabilities are present Celebrity suicides Copier identifies with completer Copier belongs to pro-suicide group Increased suicide attempts/completion shown to follow teen suicide movie broadcasts

18. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide & Marital Status Divorced rate 34.9/100,000 Widowed rate 33.2/100,000 Highest rates in young widowers age 15-34 Patterns are similar for blacks and whites

19. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide Methods Most common methods: Firearms most common (60%) More males than females (80%) In hospitals hangings most common(89%) Second most common method: Hanging in men Medication/Drugs in women

20. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide Timing Season: Higher rates in Fall and Spring Day: Monday has the highest rate Hour: Early morning hours

21. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide Attempts in the US Potentially self-injurious action Nonfatal outcome Evidence of intent to kill self May or may not result in self-harm Attempts are the strongest single predictor of completion, especially in the elderly and in the hospital setting

22. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Suicide Attempts in the US 240,000-600,000 attempts annually (2005) 1900 attempts per day Ideation 260 times as frequent as completion In the young, 100-200 attempts to 1 completion In the elderly, 4 attempts to 1 completion 20-40% of attempters made prior attempts Of second or third time attempters 4-12% completed

23. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. The Cycle of Suicide Person has feelings of helplessness & hopelessness Starts to develop thoughts of how and why “Things will be better without me” Plan The person develops/creates a plan Makes up mind to commit to the plan Give cues that end is near Places affairs in order Attempts or Commits the Plan

24. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. The A B C & D’s of Suicide Assessment and Clinical Documentation Part 2 See Kaleida Form

25. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Initial & Ongoing Suicide Lethality Assessment Forms The forms we will be discussing are attached to the back of this training session.

26. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Purpose of Assessment Forms Model for assessing suicidality in all clinical settings Example to be incorporated into institution- specific protocols Used as a “best practice” and a “standard of care” Not exhaustive and allows for clinical judgment

27. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. When to Use the Assessment Forms Psych ER & Inpatient Initial interview (Mental Health Assessment) Admission to treatment facility After self-destructive ideations/behaviors After level of precaution changes At discharge or termination

28. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. When to Use the Assessment Forms Outpatient The Initial Suicide Lethality Assessment should be completed at Intake as part of the Mental Health Assessment. The On-going Assessment is completed by the assigned counselor at the departmental level upon admission to that department as part of the Integrated Assessment. The Psychiatrist assigned to the patient reviews the On-going Assessment at the first visit and signs off on the form. The On-going Assessment if then completed yearly or as clinically dictated by the patients treatment plan and the treatment teams recommendations

29. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. A is for Assessment Suicide Ideations Present Plan What is the plan? Document means, method & how far has the present suicide plan proceeded Past Attempts What is the plan? Document means, method & how far has the present suicide plan proceeded

30. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. B is for Beliefs & Risks What was the reason for the attempt. To Express Anger To Relieve Pain To Avoid/escape To Die To Make a Statement To Make Others Suffer

31. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. B is for Beliefs & Risks Risk Factors : Substance Abuse Physical/Sexual Abuse Serious Mental Illness Impulsivity Themes surround Death & Dying Physical/Emotional Pain Suicidal Plan: Means Assault History Prior Suicide Attempts Guilt Command Hallucinations to Kill or be Killed Hopelessness Age Helplessness Sex Strong Death Wish Recent Loss Family History of Suicide Lives Alone Financial Stress/Issues Legal Problems

32. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. C is for Clinical Liabilities, Coping Skills & Protective Factors Clinical Liabilities: Substance Abuse past or present Cognitive Deficits: Delirium. Dementia, Developmental Disabilities Co-Morbid Illness: Medical or Psychiatric (e.g.. Depressed Mood, Psychosis, Mania) Affective Lability History of Poor Impulse Control

33. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. C is for Clinical Liabilities, Coping Skills & Protective Factors Coping Skills & Protective Factors: Ability to form a therapeutic alliance Capacity for affective self regulation Ability to use coping skills Willing to participate in treatment Strong Support System Religious Prohibition Future Goals

34. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. D is for Disposition & Documentation SUICIDE/LETHALITY RISK ASSESSED AS: ‫ MILD ‫ MODERATE ‫ SEVERE RISK REDUCTION STRATAGIES AS ‫ IMMEDIATE ‫ INTERMEDIATE ‫ LONG TERM

35. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. D is for Disposition & Documentation After all the information is gathered a summary note should be documented from the face to face encounter and any other clinical interventions or plan

36. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Ongoing Assessment Form The Ongoing Assessment form will be used after the Initial Assessment form is completed and updates the data and information. This form will allow for the clinician to see changes in key elements of suicide lethality

37. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Ongoing Assessment Form Key Elements: Ongoing Assessment Change in Risk Factors Change in Protective Factors Clinical Determination Risk Reduction Strategies Discussion of the lethality assessment & clinical plan Review & Comments

38. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Elements of Treatment Planning for the Suicidal Patient Part 3

39. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Elements of Treatment Planning Identify range of treatment alternatives Choose appropriate level of treatment Involve the patient Consider acute and chronic aspects Document the treatment planning process Consider risk management issues

40. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Identify Range of Treatment Alternatives Greater risk leads to more intensive treatment Assess risk and benefits of alternatives Incorporate current treatments/providers Consider Risk Reduction Strategies Consider other options: Psychosocial interventions Psychoeducation interventions Pharmacotherapeutic Interventions

41. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Psychosocial & Psychoeducational Interventions Address underlying and/or comorbid disorders Current providers should become involved Psychotherapist ICM or CM Counselor Doctor, PMD Increased contact may help during crisis

42. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Psychosocial & Psychoeducational Interventions Psychoeducation/treatment for significant others on risk and risk reduction Use of community resources MHA NAMI Religious groups

43. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Pharmacotherapeutic Interventions Treat underlying or comorbid disorders Medication is an implement for suicide or self harm Drug interactions or indications (Can medication “make people suicidal”? “Does medication reduce suicidal risk”? With the risks assessed “Do we give 30 day supply of medication”?

44. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Medications is an Implement for Suicide or Self Harm Paradox: Riskiest patients possess dangerous medications Many overdoses use prescribed medications Often combined with other methods Antidepressants are the most common Some medications have a narrow margin of safety in dosage

45. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Discharge Plan Current suicide risk assessment Living arrangements Work plan Involvement with significant others Use of community resources Follow up appointments Medications, prescriptions Individualized crisis plan

46. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Risk Management and Suicide Part 4 Informational to all clinicians Mandatory for Psychiatrists

47. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Malpractice Suits: The risk is real…. 20% of psychologists and 50% of psychiatrists will lose a patient to suicide Suicide related malpractice claims are the largest category for psychiatrists the sixth largest category for psychologists Awards are disproportionately large in these type of cases

48. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. …but adverse decisions are rare. Few claims go to trial (5-10%) Majority of trials are won by defendant The distress,nonetheless, is enormous The best risk management is preventative Sound clinical management Appropriate documentation

49. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Most Frequent Scenarios Inpatient suicide with “inadequate care and supervision” Suicide after discharge of inpatient Outpatient suicide with “inadequate treatment”

50. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. What is Malpractice? A “Tort”: A civil wrong committed by one individual that caused injury to another individual.

51. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. The Four D’s of Malpractice Dereliction (negligence) of Duty (reasonable care) Directly (proximately) causing Damages (emotional or physical)

52. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. What is Reasonable Care? Discipline-specific legal duty Implied by presence of therapist-patient relationship Degree of care which a reasonably prudent professional should exercise in similar circumstances Includes documentation “Reasonable” does not mean “optimal”

53. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Negligence Failure to meet legal standard of care Commission Omission Assumption that foresight leads to prevention

54. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Negligence in Outpatient Treatment Failure to evaluate for/give suitable pharmacotherapy Failure to hospitalize Failure to maintain appropriate relationships Failure in supervision and consultation Failure to evaluate risk at intake or transitions

55. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Negligence in Outpatient Treatment Failure to secure prior records, take adequate history, conduct MSE, or diagnose Failure to establish formal treatment plan Failure to safeguard outpatient environment Failure to adequately document

56. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Failure to evaluate for/give suitable pharmacotherapy Medications are helpful but also dangerous History of similar drug treatment must be taken into consideration Too little or wrong medication Document rationale for not using medication Hoarding medications can increase risk

57. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Risk Management & Prescribing Treat, and optimize dose (Don’t undertreat) Use least toxic drug available No routine refills without monitoring Limit quantities of refills appropriately Employ pill counts with high risk patients Beware of attempt to obtain instrument for suicide Don’t stop medications abruptly Follow up on missed appointments Increase intensity of treatment as appropriate

58. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Failure to hospitalize Define level of treatment on basis of level of risk Hospitalization does not prevent suicide 1% of suicides occur in hospitals 15 minute checks may be inadequate

59. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Failure to maintain appropriate relationships Boundary violations Sexual intimacies followed by patient’s suicide Nonsexual boundary violations Regressive therapies

60. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Failure in supervision & consultation Majority of psychologists do some supervision Negligent supervision: “lawsuit of the failure” Respondent superior (vicarious liability) Assignment of high risk activities to trainees Supervisor must be knowledgeable in treatment area Supervisor must assess training, competence of trainee Patient must give informed consent to treatment with trainee

61. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Failure to evaluate risk At intake At “one-shot” consultation At management transitions At discharge

62. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Failure to take adequate history or to secure prior records Determine access to weapons Consult prior providers or records Past suicidal behavior Past treatment and effects Family history of mental illness

63. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Failure to conduct MSE & Diagnose Mood disturbance Thought disorder Cognitive impairment Substance abuse Medical diagnosis

64. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. “If it isn’t written down, it didn’t happen” -- Gutheil Document the assessment of risk What information was considered High-risk factors, low risk factors What questions were asked, what answers were given How did this information lead to plan “Thinking out loud for the record”

65. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Failure to document adequately The chart is a “contemporaneous record” Record collateral contacts, relevant phone calls Record consultations Never alter record subsequently

66. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Negligence in Inpatient Treatment Failure to predict Failure to control, supervise, or restrain Failure to remove belt or dangerous objects Failure to place in secure room Failure to take proper tests Failure to medicate properly Failure to observe continuously or frequently Failure to take adequate history

67. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Bell v New York City Health & Hospital Corporation (1982) Negligent care with bad outcome Early release of patient preceded suicide Defendant psychiatrist found liable, failed to: Inquire re nature of auditory hallucinations Request prior treatment records Notice recent restraints in chart Communicate with hospital staff

68. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Dillman v Hellman (1973) Reasonable care with bad outcome Patient jumped from psychiatric hospital window following transfer to less secure area of hospital Psychiatrist defendant not liable Accepted standard of care had been met Physicians “cannot ensure results” Documentation in chart was deciding factor for care

69. Click the arrows to advance forward and backward. Click the Next link below to advance to the assessment. Summary of Risk Management Manage risk preventatively, not retroactively Understand how to assess suicide risk Assess risk initially and repeatedly Know legal and ethical guidelines for treatment Plan and implement treatment & risk reduction strategies appropriately Consult when indicated Document effectively