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

2. 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

3. 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

4. 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%

5. 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

6. 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

7. 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

8. 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)

9. 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

10. 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!

11. Determine Risk Level / Intervention
NSW Risk Assessment Guide
CSUS Suicide Risk Assessment
mmary.pdf
ACP Assessment of Suicidal Ideation
Harvard Risk Management Guidelines
Algorithms/2011/~/media/Files/_Global/KC/PDFs/suicideAs
SAMHSA Grid

12. Determination of Risk / Intervention
BHS – ED
MHTS
MSHR
ReACT Self Harm Rule
Beck's SIS
DSI – SS
GDS
RAM
SIQ
SIQ – JR
VASA
NGASR
RSQ

13. Do not leave the person unattended
Now What?
Do not leave the person unattended
Call County Crisis Line or TALK
Clackamas
Multnomah
Washington
Arrange for transport to the nearest available hospital for evaluation
“Safety contracts” don't prevent suicide

14. Legal – ORS
(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.

15. 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 (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]

16. 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?

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