Transcript Suicide Prevention

Suicide Risk Assessment
A Brief Introduction for Helpers
Updated 19-09-13
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18 September 2013
Global economic crisis
'linked to suicide rise'
Researchers from the universities of Oxford and Bristol in the UK, along with colleagues from
Hong Kong University, used data from the World Health Organization mortality database, the
Centers for Disease Control and Prevention and the International Monetary Fund's World
Economic Outlook database.
In 2009, there was a 37% rise in unemployment and 3% falls in GDP per capita, reflecting the
onset of the economic crisis in 2008.
There were nearly 5,000 'extra' suicides above the expected level for that year.
The financial crisis "almost certainly" led to an increase in suicides across Europe, health
experts say.
The analysis by US and UK researchers found a rise in suicides was recorded among working age
people from 2007 to 2009 in nine of the 10 nations studied. The increases varied between 5%
and 17% for under 65s after a period of falling suicide rates, The Lancet reported.
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2 May 2013
Suicides soar among US
middle-aged people
The suicide rate among middle-aged Americans rose 28% in a decade, a new report from the
Centers for Disease Control (CDC) has found.
Since 2009, suicide has claimed more Americans than motor vehicle crashes.
There were 38,350 suicides in 2010, making it the nation's 10th leading cause of death, the CDC
said.
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7 September 2013
Suicides cost Japan
economy $32bn
The government in Japan says suicides and depression cost its economy almost 2.7tn yen
($32bn; £21bn) last year.
The figures refer to lost incomes and the cost of treatment. It is the first time Japan has released
such figures.
Japan has one of the world's highest suicide rates, with more than 32,000 people killing
themselves last year. PM Naoto Kan sees it as proof of an economic and emotional downturn.
In a country in which stoicism and consensus are highly valued, many older people in particular
view mental illness as a stigma that can be overcome simply by trying harder, they say.
The use of psychotherapy to treat depression has lagged behind North America and Europe,
with Japanese doctors often viewing medication as the sole answer, they add.
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18 September 2013
One in three 'behind on rent'
since housing benefit changes
One in three council tenants affected by a recent cut to housing benefit has fallen behind on
rent since the policy took effect, figures suggest. The TUC's False Economy campaign made
Freedom of Information requests to all of Britain's councils; 114 responded.
Data revealed 50,000 tenants had fallen into arrears since 1 April 2013 when the housing benefit
changes came in - a move critics called the bedroom tax.
The council with the greatest percentage of tenants who had fallen behind was Barrow in northwest England. Of the 289 tenants there affected by the cut, 219 have not been able to pay rent
since the policy came into effect.
The National Housing Federation has also carried out a survey looking at the numbers of tenants
in arrears. It found that a quarter of households affected by the cut have fallen behind in their
rent for the first time ever - 11,000 out of 44,000 households were in arrears according to data
given by 38 of England's housing associations.
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Introduction
• This is not meant to be a detailed guide to the specialised area of
suicide prevention or suicide risk assessment
• This presentation provides an introduction to the subject of
recognising and intervening safely with clients who may present a
risk of suicide
• It is intended for volunteer helpers to support their work with the
Serenity Programme™
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Contents
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Recognising depression
Typical thought and speech patterns of people at risk of suicide
A semi-structured interview for risk assessment (Meichenbaum)
Factors associated with suicide risk
Risk and protective factors
The ‘PALS’ assessment
Additional resources – SBQ-R, Pierce, PHQ-9 etc.
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Depression prevalence
• Depression is the fourth leading cause of disability and disease
worldwide
• It is estimated that depression will become the second most
common cause of disability, after heart disease, by 2020
• Unipolar forms of depression are more common in women than
men. In Britain 3-4% of men and 7-8% of women are thought to
suffer from moderate to severe depression at any one time
• The incidence of dysthymia (sub-threshold depressive symptoms
persisting for more than 2 years) increases with age; 2.5–5% of
people will experience dysthymia during their lifetime (Waraich et
al, 2004)
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Types of depression
• Major depressive disorder – diagnosed by the person feeling 5 or
more of the symptoms of depression, lasting over 2 weeks
• Adjustment disorder – milder and shorter-lived forms of
depression, often resulting from stressful experiences
• Dysthymia – long-term symptoms of depression (of at least 2 years)
which are not severe enough to meet criteria for major depression
• Post-natal depression – occurs after childbirth (also peri-natal
depression, which can occur during pregnancy but which is less
common)
• Seasonal Affective Disorder (SAD) – depression associated with
lack of daylight and shorter daylight hours in winter
• Bipolar disorder (sometimes called manic depression)
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Recognising depression (1 of 2)
• Symptoms of depression can appear over a period of months or
years or in the case of bipolar disorder, suddenly and escalate over
just a few days
• In diagnostic terms, 5 of the following should be present during the
same 2-week period and have caused a change from previous
functioning
• For a major depressive episode, symptoms must appear on a
daily basis and last most, or all of the day
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Recognising depression (2 of 2)
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Depressed mood (sad, hopeless or empty)
Markedly diminished pleasure in all (or almost all) activities
Insomnia or hypersomnia
Increase or decrease in appetite or significant weight loss
Fatigue or loss of energy
Feelings of worthlessness
Excessive or unwarranted guilt
Diminished ability to think, concentrate or take decisions
Recurrent thoughts of death, suicidal ideation, having a suicide plan
or making a suicide attempt
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Antidepressants
• Antidepressants can be very effective in helping people recover
from depression but can also be used to attempt suicide through
overdose. There is no clear evidence to show that they reduce
suicide or self harm
• Selective Serotonin Reuptake Inhibitors (SSRI) are thought to cause
suicidal thoughts and behaviour in some people. Current research
suggests that this is true for children and adolescents but there is
currently no evidence to support the heightened suicide risk in
adults
• There may be a period of increased risk if motivation to act
improves before mood
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Suicide risk
• For people with severe depression, the lifetime risk of suicide may
be as high as 6%, compared with a risk of 1.3% in the general
population
• For those with bipolar disorder, suicide risk is 15 times that of the
general population
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Suicide risk assessment
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Is, in itself, treatment
Takes place in an empathic, therapeutic relationship
Is unique for each individual
Is complex and challenging
Is an ongoing process
Errs on the side of caution
Is collaborative and relies on effective communication
Relies on clinical judgement
Takes all threats, warning signs, and risk factors seriously
Asks the ‘tough questions’
Tries to uncover the underlying message
Is carried out in a culturally-sensitive manner
Is well documented
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Adapted from Meichenbaum, D.
Thinking patterns (1 of 2)
• Dichotomous (either-or) thinking
• Cognitive rigidity and constriction
• Perfectionistic standards toward self and others with high levels of
self-criticism
• Lack of specificity in autobiographical memory, overgeneral and
vague memory interferes with problem-solving because past cannot
be used as references for coping in the present
• Low confidence in problem-solving ability
• ‘Looming vulnerability’ - the perceived experience of negative
occurrences as rapidly escalating, quickly approaching adversities
that generate distress
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Thinking patterns (2 of 2)
• Hopelessness and helplessness with negative expectations about
the future
• Ruminative process – feeling cornered, unable to consider
alternatives
• Present-oriented and view death in a relatively favourable light
• Difficulty generating reasons for living
• Absence of protective factors such as attraction to life, repulsion by
death, surviving and coping beliefs, sense of personal self-efficacy,
moral and religious objections to suicide, fear of self-injury and
sense of responsibility to family
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Characteristic speech content (1 of 3)
‘I can't stand being so depressed anymore’ ‘I am damaged goods’
(Intractable emotional pain)
‘Suicide is the only choice I have left’ (Only one or two choices –
dichotomous thinking)
‘My family would be better off without me’ ‘I am worthless. They
would be better off if I were dead’ ‘I am worth more dead than
alive’ (Perception of being a burden on others)
‘I am useless and unwanted’ (Feel unattached, perceive others as
uncaring and unsupportive; feel socially disconnected and lack
emotional intimacy)
‘No one cares whether I live or die’ (Feel rejected, marginalised,
worthless, unlovable, isolated, alone, a failure)
‘I am worthless and don’t deserve to live’ (Guilt and shame)
‘I am a bad person, I have to escape’ (Escape from self)
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Characteristic speech content (2 of 3)
‘I feel I am crashing, like a freight train or like a wave has hit me. There
is no hope. What’s the point?’ (suicidal individuals are prone to
produce elaborate mental scenarios anticipating rapidly rising risk
with multiply increasing threats. Tend to exaggerate the time course
of perceived catastrophic outcomes and have an increased sense of
urgency for escape and avoidance)
‘I hate myself’ (Suicidal individuals have an over-generalised memory
and tend to selectively recall negative events that contribute to selfloathing)
‘I can’t fix it, I should just die’ (Tunnel vision, inflexibility in generating
alternatives, feeling trapped and perceived inescapability)
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Characteristic speech content (3 of 3)
‘I would rather die than feel like this forever’ (Low distress tolerance
and inability to consider future possibility of change)
‘I have lost everything important to me’ ‘My life is empty’ ‘Life is not
worth living’ ‘Nothing will change’ ‘What’s the point?’ ‘My life has
no purpose’ (Helplessness, hopelessness and meaninglessness)
‘I have screwed up, so I might as well screw up all the way’ (‘when in a
hole – keep digging’)
‘They’ll be sorry’ ‘They will miss me when I’m gone’ (post-mortem
revenge)
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Very High Risk
Seek immediate
professional help
High Risk
Seek professional
help
Lower Risk
Monitor for development
of warning signs
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Adapted from Rudd et al, 2006
What would you do if …
• A client calls you on the telephone saying they are going to kill
themselves …
• What would you want to know?
• Work first individually, then as a group …
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‘Risk’ & ‘Protective’ Factors
Relationships
Hope
Faith
Work
Loss
Depression
Hopelessness
Impulsivity
‘Protective’ factors may not mean just the presence of something – it may also mean
the absence of something – for example, the absence of access to means of suicide
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Factors associated with risk (1 of 3)
Direct indices of imminent risk for suicide or parasuicide …
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Suicide ideation
Suicide threats
Suicide planning and or preparation
Parasuicide in last 12 months
Adapted from ‘A social-Behavioral Analysis of Suicide and parasuicide: Implications for Clinical Assessment and Treatment’ by M.M. Linehan (1981),
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in H. Glaezer & J.F. Clarkin (eds.), Depression: Behavioral and Directive Intervention Strategies. New York: Garland
Factors associated with risk (2 of 3)
Indirect indices of imminent risk for suicide or parasuicide …
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Client falls into suicide or parasuicide risk populations
Recent disruption of loss of relationship
Negative environmental change in last month
Recent hospital discharge
Indifference to, or dissatisfaction with therapy
Current hopelessness, anger or both
Recent medical care
Indirect references to own death, arrangements for death
Abrupt clinical change, either negative or positive
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Factors associated with risk (3 of 3)
Circumstances associated with suicide or parasuicide in next several
hours or days …
• Depressive turmoil, severe anxiety, panic attacks, severe mood
cycling
• Alcohol or drug use
• Suicide note written or in progress
• Availability of methods
• Isolation
• Precautions against discovery or intervention, deception or
concealment about timing, place etc.
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PALS - Proximity to others
‘P’ = Proximity to Others
• How isolated is the client? Are there any significant others around
who might be potential rescuers and interfere or otherwise foil the
client’s plan?
• Can others be encouraged to actively defuse the client’s plan - e.g.
hide guns or confiscate pills?
• Clients with few significant relationships are at higher risk
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PALS - Proximity to others
Which plan below is most likely to be foiled by others?
• A. I am going to go into the girls toilets at school and take an
overdose
• B. I am going to wait till my parents have left for work and then go
into the basement and slash my wrists
• C. I am going to go to my boyfriend's house during his birthday
party and hang myself in his backyard
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PALS - Proximity to others
Which plan below is most likely to be foiled by others?
• A. I am going to go into the girls toilets at school and take an
overdose (possible answer – toilets are public places)
• B. I am going to wait till my parents have left for work and then go
into the basement and slash my wrists
• C. I am going to go to my boyfriend's house during his birthday
party and hang myself in his backyard (very high likelihood of
intervention by others)
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PALS - Availability of means
‘A’ = How accessible is weapon or means of self harm?
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Does the client have a gun, knife, pills etc. in his or her possession?
Do they have to steal, borrow or purchase them?
How easily can means of self harm be obtained?
Means of self harm already in client’s possession are most risky
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PALS - Availability of means
Which of the means below is most accessible?
• A. I have got a large carving knife stashed in the back of my bottom
drawer
• B. I am going to get my psychiatrist to write me a large prescription
for barbiturates
• C. I am going to go out on the street and find a drug dealer who will
sell me a large dose of heroin
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PALS - Availability of means
Which of the means below is most accessible?
• A. I have got a large carving knife stashed in the back of my bottom
drawer (readily available nearby)
• B. I am going to get my psychiatrist to write me a large prescription
for barbiturates
• C. I am going to go out on the street and find a drug dealer who will
sell me a large dose of heroin (Both ‘B’ & ‘C’ rely on the
cooperation of others to obtain the means)
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PALS - Lethality of means
‘L’ = Lethality of Means
• How precipitous is the method of self harm? Once started can the
method be reversed?
• Guns, jumping from great heights and jumping in front of moving
vehicles are highly lethal
• Cutting and overdoses may be relatively less lethal because people
might be able to can change their minds …
• Precipitous methods in a plan are more serious and more lethal
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PALS - Lethality of means
Which of the means below is least likely to be harmful?
• A. I am going to get my husband's loaded revolver and blow my
brains out
• B. I am going to jump off a the bridge over the A55 at 5 o’clock
• C. I am going to take a whole bottle of antibiotics left over from my
last urinary track infection
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PALS - Lethality of means
Which of the means below is least likely to be harmful?
• A. I am going to get my husband's loaded revolver and blow my
brains out (very precipitous and lethal)
• B. I am going to jump off a the bridge over the A55 at 5 o’clock
(highly lethal)
• C. I am going to take a whole bottle of antibiotics left over from my
last urinary track infection (antibiotics are not usually lethal in
overdose)
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PALS - Specificity of plan
‘S’ = Specificity of Plan
• How detailed is the client’s plan?
• Have they thought of a place, time or deadline for the act?
• Have they made special arrangements to make the plan work?
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PALS - Specificity of plan
Which plan below is most specific and therefore most risky?
• A. I am going to hurt myself so my partner will appreciate me more
• B. I am going to drive my father's new car off a bridge on my
parent's anniversary next week!
• C. I am going to get a prescription of pills and take them when no
one is around
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PALS - Specificity of plan
Which plan below is most specific and therefore most risky?
• A. I am going to hurt myself so my partner will appreciate me more”
(neither method, time nor place specified)
• B. I am going to drive my father's new car off a bridge on my
parent's anniversary next week”(method, time and deadline
specified)
• C. I am going to get a prescription of pills and take them when no
one is around”(what kind of drug, how will they get it and when will
it be taken?)
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Care …
• PALS Scale is not predictive when PSYCHOSIS and / or SUBSTANCE
ABUSE are present
• Alcohol, drugs and severe mental illness may distort judgement
such that the risk of suicide, intentional or otherwise, increases
significantly
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References
Glaezer, H. & Clarkin, J.F. (Eds.), Depression: Behavioral and Directive Intervention Strategies. New York: Garland
Press.
Lalkhen, A. G , McCluskey, A. (2008) Clinical tests: Sensitivity and specificity. Continuing Education in Anaesthesia,
Critical Care and Pain 2008(8) p. 221-223. Available from:
http://ceaccp.oxfordjournals.org/content/8/6/221.full Accessed on 22-04-12.
Meichenbaum, D. 35 Years of working with suicidal patients: Lessons learned. Available from:
www.melissainstitute.org/documents/35_Years_Suicidal_Patients.pdf Accessed on 21-04-12
Osman, A., Bagge, C. L., Gutierrez, P. M., Konick, L. C., Kopper, B. A., & Barrios, F. X. (2001). The Suicidal Behaviors
Questionnaire-Revised (SBQ-R): Validation with clinical and nonclinical samples. Assessment, 8(4), 443-454.
Rudd, M.D., Berman, A.L., Joiner, T.E., Nock, M.K., Silverman, M.M., Mandrusiak, M., Orden, K., & Witte, T. (2006).
Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life Threatening Behaviour, 36,
255-62.
Samaritans information sheet. Available from:
http://www.samaritans.org/pdf/Samaritans-MentalHealthAndSuicide.pdf Accessed on 21-04-12.
Waraich, P., Goldner, E.M., Somers, J.M. & Hsu, L. (2004) Prevalence and incidence studies of mood disorders: A
systematic review of the literature. Canadian Journal of Psychiatry 49(2), 124-138.
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Thanks for Listening!
Questions?
Additional material
• Additional information follows relevant to scoring the SBQ-R …
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Sensitivity
• The sensitivity of a clinical test refers to it’s ability to correctly
identify those with the disease
• A test with 100% sensitivity correctly identifies all patients with the
disease. A test with 80% sensitivity detects 80% of patients with the
disease (true positives) but 20% with the disease remain
undetected (false negatives)
Sensitivity =
True positives
[True positives + False negatives]
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Specificity
• The specificity of a test refers to it’s ability to correctly identify
people without the disease
• A test with 100% specificity correctly identifies all patients without
the disease. A test with 80% specificity correctly reports 80% of
patients without the disease as test negative (true negatives) but
20% patients without the disease are incorrectly identified as test
positive (false positives)
Specificity =
True negatives
[True negatives + False positives]
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Sensitivity and specificity
• A test with a high sensitivity but low specificity results in many
disease – free patients being told they have the disease
• Although the ideal (unrealistic) situation is for a 100% accurate test,
a good alternative is to subject patients who are initially positive to
a test with high sensitivity / low specificity to a second test with low
sensitivity / high specificity
• This way, nearly all the false positives can be correctly identified as
disease negative
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PPV and NPV
• The Positive predictive value (PPV) of a test answers the question:
‘How likely is it that this person has the disease
given that the test result is positive?’
• The Negative predictive value (NPV) of a test answers the question:
‘How likely is it that this person does not have the disease
given that the test result is negative?’
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Receiver operator characteristics
• Receiver operator characteristic curves are a plot of (1−specificity)
of a test on the x-axis against its sensitivity on the y-axis for all cutoff values
• An identical plot is produced when the false positive rate of a test is
shown on the x-axis against the true positive rate on the y-axis
• An ideal test is represented by the upper curve in the figure (‘C’).
The middle curve represents the characteristics of a test more
typically seen in routine clinical use (‘B’)
• The area under this curve (AUC) represents the overall accuracy of a
test, with a value approaching 1.0 indicating a high sensitivity and
specificity
• The dotted line on the graph (‘A’) shows the ‘line of zero
discrimination’ with an AUC of 0.5 (no better than tossing a coin)
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Receiver operator characteristic curves
(A) Line of zero discrimination (AUC = 0.5)
(B) Typical clinical test (AUC = 0.5 – 1.0)
(C) Theoretically ‘perfect’ test (AUC = 1.0)
Lalkhen, A. G , McCluskey, A. Continuing Education in Anaesthesia, Critical Care and Pain 2008(8) p. 221-223.