Suicide Risk and Suicide Risk and Violence Threat Violence Threat

AssessmentAssessment

Developed by DATA of Rhode IslandDeveloped by DATA of Rhode Island through a grant from the RI Department of Human Servicesthrough a grant from the RI Department of Human Services

Part 1:Suicide AssessmentPart 1:Suicide Assessment

GOALSGOALS

• Participants to increase knowledge of Participants to increase knowledge of suicide risk factorssuicide risk factors

• To understand which risk factors To understand which risk factors should most of concernshould most of concern

• To understand when and how the To understand when and how the worker should intervene?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 COMPONENTS OF SUICIDE ASSESSMENTASSESSMENT

Survey and identify client risk Survey and identify client risk factors and protective factors factors and protective factors Elicit direct client communication Elicit direct client communication about suicideabout suicideReview previous HistoryReview previous History

SUICIDE: Contributing Factors

Neurobiology

Severe MedicalIllness

Impulsiveness

Access To Weapons

Hopelessness

Life Stressors

Family History

SuicidalBehavior

Personality Disorder/Traits

Psychiatric IllnessCo-morbidity

Psychodynamics/Psychological Vulnerability

Substance Use/Abuse

Suicide

Areas to Evaluate in Suicide AssessmentAreas to Evaluate in Suicide Assessment

Psychiatric Psychiatric

IllnessesIllnesses

Comorbidity, Comorbidity, Affective Disorders, Alcohol / Substance Abuse, Affective Disorders, Alcohol / Substance Abuse, Schizophrenia, Cluster B Personality disorders.Schizophrenia, Cluster B Personality disorders.

HistoryHistory Prior suicide attempts, aborted attempts or self harm; Medical Prior suicide attempts, aborted attempts or self harm; Medical diagnoses, Family history of suicide / attempts / mental illnessdiagnoses, Family history of suicide / attempts / mental illness

Individual Individual strengths / strengths /

vulnerabilitiesvulnerabilities

Coping skills; personality traits; past responses to stress; Coping skills; personality traits; past responses to stress; capacity for reality testing; tolerance of psychological paincapacity for reality testing; tolerance of psychological pain

Psychosocial Psychosocial situationsituation

Acute and chronic stressors; changes in status; quality of Acute and chronic stressors; changes in status; quality of support; religious beliefssupport; religious beliefs

Suicidality and Suicidality and SymptomsSymptoms

Past and present suicidal ideation, plans, behaviors, intent; Past and present suicidal ideation, plans, behaviors, intent; methods; hopelessness, anhedonia, anxiety symptoms; methods; hopelessness, anhedonia, anxiety symptoms; reasons for living; associated substance use; homicidal reasons for living; associated substance use; homicidal ideationideation

Adapted from APA guidelines for suicide assessment

RISK FACTORS

DemographicDemographic male; widowed, divorced, single; increases with age; male; widowed, divorced, single; increases with age; whitewhite

PsychosocialPsychosocial lack of social support; unemployment; drop in socio-lack of social support; unemployment; drop in socio-economic status; economic status; firearm accessfirearm access

PsychiatricPsychiatric psychiatric diagnosispsychiatric diagnosis; comorbidity; comorbidity

Physical IllnessPhysical Illness Cancer; HIV/AIDS; systemic lupus; pain syndromes; Cancer; HIV/AIDS; systemic lupus; pain syndromes; functional impairment; diseases of CNSfunctional impairment; diseases of CNS

Psychological Psychological DimensionsDimensions

hopelessness; pain/anxiety; psychological turmoil; low hopelessness; pain/anxiety; psychological turmoil; low self-esteem; fragile narcissism & perfectionismself-esteem; fragile narcissism & perfectionism

Behavioral Behavioral DimensionsDimensions

impulsivity; aggression; severe anxiety; panic attacks; impulsivity; aggression; severe anxiety; panic attacks; agitation; intoxicationagitation; intoxication; prior suicide attempt; prior suicide attempt

Cognitive Cognitive DimensionsDimensions

thought constriction; polarized thinkingthought constriction; polarized thinking

Childhood Childhood TraumaTrauma

sexual/physical abuse; neglect; parental losssexual/physical abuse; neglect; parental loss

Genetic & Genetic & FamilialFamilial

family history of suicide, mental illness, or abusefamily 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

COMORBIDITYCOMORBIDITY

In general, the more diagnoses In general, the more diagnoses present, the higher the risk of present, the higher the risk of suicide.suicide.

50% had multiple Axis I and at least 50% had multiple Axis I and at least one Axis III diagnosis (medical one Axis III diagnosis (medical problems) problems)

44% had 2 or more Axis I diagnoses44% had 2 or more Axis I diagnoses

31% had Axis I and Axis II diagnoses31% had Axis I and Axis II diagnoses

Only 12 % had a single Axis I Only 12 % had a single Axis I diagnosis with no comorbiditydiagnosis 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 SUICIDESCHIZOPHRENIA AND SUICIDE

High-Risk Profile:High-Risk Profile: Previous suicide attempt(s)Previous suicide attempt(s) Significant depressive symptoms - hopelessnessSignificant depressive symptoms - hopelessness Male genderMale gender First decade of illness – (however, rate remains elevated First decade of illness – (however, rate remains elevated

throughout lifetime)throughout lifetime) Poor premorbid functioningPoor premorbid functioning Current substance abuseCurrent substance abuse Poor current work and social functioningPoor current work and social functioning Recent hospital dischargeRecent hospital discharge

Suicide occurs later in the course of the illness with Suicide occurs later in the course of the illness with communications of suicidal intent lasting several yearscommunications of suicidal intent lasting several years

In completed suicides, men have higher rates of alcohol In completed suicides, men have higher rates of alcohol abuse, women have higher rates of drug abuseabuse, women have higher rates of drug abuse

Increased number of substances used, rather than the Increased number of substances used, rather than the type of substance appears to be importanttype of substance appears to be important

Comorbid psychiatric disorders, females have Comorbid psychiatric disorders, females have Borderline Personality DisorderBorderline Personality Disorder

High Risk Profile:High Risk Profile: Recent or impending interpersonal lossRecent or impending interpersonal loss Comorbid depressionComorbid depression

ALCOHOL / SUBSTANCE ABUSE AND SUICIDE

PERSONALITY DISORDERS AND SUICIDEPERSONALITY 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 FACTORSGENETICS FACTORS

Suicide appears to be an independent, Suicide appears to be an independent, inheritable risk factor.inheritable risk factor.

Relatives of suicidal subjects have a Relatives of suicidal subjects have a four-foldfour-fold increased risk compared to relatives of non-increased risk compared to relatives of non-suicidal subjects.suicidal subjects.

Higher concordance of suicidal behavior Higher concordance of suicidal behavior between identical rather than fraternal twins.between identical rather than fraternal twins.

Adoption studies: a greater risk of suicide Adoption studies: a greater risk of suicide among biologic rather than adoptive relatives. among biologic rather than adoptive relatives.

Family history of abuse, violence, or other self-Family history of abuse, violence, or other self-destructive behaviors place individuals at destructive behaviors place individuals at increased risk for suicidal behaviors increased risk for suicidal behaviors

Histories of childhood physical abuse and sexual Histories of childhood physical abuse and sexual abuse, as well as parental neglect and abuse, as well as parental neglect and separations, are correlated with a variety of self-separations, are correlated with a variety of self-destructive behaviors in adulthooddestructive behaviors in adulthood

FAMILY PSYCHOPATHOLOGYFAMILY 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, Firearms account for 55-60% of suicides (Baker 1984, Sloan 1990).Sloan 1990).

Firearms at home increase riskFirearms at home increase risk

• Guns are twice as likely to be found in the homes of Guns are twice as likely to be found in the homes of suicide victims as in the homes of attempters suicide victims as in the homes of attempters

• Type of gun (handgun, rifle, etc.) was not statistically Type of gun (handgun, rifle, etc.) was not statistically correlated with increased risk for suicide correlated with increased risk for suicide

Risk management point: Inquire about firearms Risk management point: Inquire about firearms

Document question and response.Document question and response.

PSYCHOSOCIAL SITUATION:PSYCHOSOCIAL SITUATION:FIREARMS AND SUICIDEFIREARMS 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 IDEATIONCOMPONENTS OF SUICIDAL IDEATION

Intent:Intent:Expectation and desire for a self-Expectation and desire for a self-destructive act to end in death.destructive act to end in death.

Lethality:Lethality:Objective danger to life associated with a Objective danger to life associated with a suicide method or action. suicide method or action.

Degree of ambivalence - wish to live, wish to Degree of ambivalence - wish to live, wish to diedie

Intensity, frequencyIntensity, frequency Rehearsal/availability of methodRehearsal/availability of method Presence/absence of suicide note Presence/absence of suicide note Deterrents (e.g. family, religion, positive Deterrents (e.g. family, religion, positive

therapeutic relationship, positive support therapeutic relationship, positive support system - including work)system - including work)

CHARACTERISTICS OF A SUICIDE PLANCHARACTERISTICS OF A SUICIDE PLAN

Risk / Rescue Issues:Risk / Rescue Issues:

MethodMethod

Time Time

PlacePlace

Available meansAvailable means

Arranging sequence of eventsArranging sequence of events

PSYCHIATRIC SYMPTOMS PSYCHIATRIC SYMPTOMS MOST ASSOCIATED WITH MOST ASSOCIATED WITH

SUICIDESUICIDE

Hopelessness/DepressionHopelessness/Depression

Impulsivity / AggressionImpulsivity / Aggression

AnxietyAnxiety

Command hallucinationsCommand 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 / AGGRESSIONIMPULSIVITY / AGGRESSION

contributes to suicidal behaviorcontributes to suicidal behavior

It is important to assess level of It is important to assess level of impulsiveness when assessing for suicidality impulsiveness when assessing for suicidality and threat to othersand threat to others

Suicide attempters may be more likely to Suicide attempters may be more likely to present traits of impulsiveness / aggression present traits of impulsiveness / aggression regardless of psychiatric diagnosis regardless of psychiatric diagnosis

Equally Important in assessing risk of Equally Important in assessing risk of murder-suicidemurder-suicide

ANXIETYANXIETY Anxiety symptoms (independent of an anxiety disorder) Anxiety symptoms (independent of an anxiety disorder)

associated with suicide risk:associated with suicide risk: Panic AttacksPanic Attacks Severe Psychic Anxiety (subjective anxiety)Severe Psychic Anxiety (subjective anxiety) Anxious RuminationsAnxious Ruminations AgitationAgitation

In a review of inpatient suicides 79% met criteria for severe In a review of inpatient suicides 79% met criteria for severe or extreme anxiety or agitationor 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 DIRECT QUESTIONING ABOUT SUICIDE:SUICIDE:

Don’t be afraid to ask direct questions. Don’t be afraid to ask direct questions.

Normalizing techniques help initiate the Normalizing techniques help initiate the conversationconversation

Example: Worker: “People who have Example: Worker: “People who have experienced losses and who are experienced losses and who are depressed, sometimes think that maybe depressed, sometimes think that maybe life is no longer worth living. Have you life is no longer worth living. Have you ever felt that way?ever felt that way?

If the client answers positively to suicidal If the client answers positively to suicidal thoughts, ask more specific questionsthoughts, ask more specific questions

COMPONENTS OF SUICIDE COMPONENTS OF SUICIDE ASSESSMENT RevisitedASSESSMENT Revisited

Survey and identify client risk Survey and identify client risk factors and protective factors factors and protective factors Elicit direct client communication Elicit direct client communication about suicideabout suicideReview previous history for suicide Review previous history for suicide and other risk factorsand other risk factors

DETERMINING OF THE LEVEL OF DETERMINING OF THE LEVEL OF RISKRISK

Evidence of suicidal ideation always deserves a Evidence of suicidal ideation always deserves a response. In determining risk level:response. In determining risk level:

Previous suicidal historyPrevious suicidal history The more immediate the plan, the higher the riskThe more immediate the plan, the higher the risk The more impaired (MH or alcohol), the higher the The more impaired (MH or alcohol), the higher the

riskrisk Access to meansAccess to means Remember, suicide risk will need to be reassessed Remember, suicide risk will need to be reassessed

at various points over time, as a patient’s risk level at various points over time, as a patient’s risk level will wax and wane.will wax and wane.

DETERMINE A RESPONSE DETERMINE A RESPONSE SET A PLANSET A PLAN

Always attend to issue of patient’s Always attend to issue of patient’s safety first.safety first.

Consult others Consult others Consult PCH or Mental Health ProviderConsult PCH or Mental Health Provider In situations of potential imminent In situations of potential imminent

danger, confidentiality is waiveddanger, confidentiality is waived Don’t rely on clients to follow throughDon’t rely on clients to follow through If all else fails, call 911If all else fails, call 911 Document, document, documentDocument, document, document

Observable SymptomsObservable Symptoms Any suicidal behavior or ideation.Any suicidal behavior or ideation. Actual statements made by clientActual statements made by client Known Risk FactorsKnown Risk Factors The issue of firearms:The issue of firearms:If present - document If present - document

If absent - document as pertinent negative (no guns in If absent - document as pertinent negative (no guns in house)house)

Actions Taken by YouActions Taken by YouWith whom, when and outcomeWith whom, when and outcome

Any follow upAny follow up

What to DocumentWhat 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 OCCURSWHEN A SUICIDE OCCURS

Despite best our efforts suicides can and do occurDespite best our efforts suicides can and do occur

Approximately, 12,000-14,000 suicides per year.Approximately, 12,000-14,000 suicides per year.

To facilitate the aftercare process:To facilitate the aftercare process:

Ensure that the client records are completeEnsure that the client records are complete

Be available to assist grieving family membersBe available to assist grieving family members

Remember document all activities and interventionsRemember document all activities and interventions

Seek support from colleagues / supervisorsSeek support from colleagues / supervisors

Consult risk managers if availableConsult risk managers if available

QuestionsQuestions