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RISK ASSESSMENT OF SUICIDE Dr. Saman Yousuf 16 June 2011 Essential points to remember • Good communication is vital • Information gathering is crucial • Investment in a thorough assessment is essential • Second opinion / de-briefing / supervision • Time Components of assessment • Appreciate the complexity of suicide; multiple contributing factors • Conduct a thorough psychiatric examination; identifying risk and protective factors and distinguishing modifiable risk factors from the rest • Ask directly about suicide - The Specific Suicide Inquiry • Determine level of suicide risk: low, moderate, high, extreme risk • Determine treatment setting and plan • Document assessments History – taking / Collateral information Risk Factors Protective Factors Modifiable Risk Factors Risk Level Specific Suicide Inquiry Psychiatric Illness Co-morbidity Personality Disorder/Traits Exposure to suicide Impulsiveness Substance Use/Abuse Hopelessness Suicide Severe Medical Illness Access To Means Family History Psychodynamics/ Psychological Vulnerability Life Stressors Suicidal Behavior Warning signs • Clues that signal the possible presence of suicidal thinking • Collateral informants may report during history taking • • • • • • • • • • • Suicide notes Direct & indirect suicide threats Making final arrangements Giving away prized possessions Talking about death Reading, writing, and/or art about death Hopelessness or helplessness Social Withdrawal and isolation Lost involvement in interests & activities Increased risk-taking Heavy use of alcohol or drugs • Abrupt changes in appearance • Sudden weight or appetite change • Sudden changes in personality or attitude • Inability to concentrate/think rationally • Sudden unexpected happiness • Sleeplessness or sleepiness • Increased irritability or crying easily • Low self esteem • Dwindling academic performance • Abrupt changes in attendance • Failure to complete assignments • Lack of interest and withdrawal • Changed relationships • Despairing attitude Barriers to the assessment • Patient’s baises and fears - Feels suicide to be a sign of weakness and is ashamed - Feels suicide is immoral and a sin - Feels discussion of suicide is a taboo subject? - Feels he will be “locked up” if suicidal ideation is admitted - Truly wants to die and does not want anyone to know - Does not think anyone can help • Your baises and fears - Do you feel suicide to be a sign of weakness? - Do you feel suicide is immoral and a sin? - Do you feel discussion of suicide is a taboo subject? - Do you feel it is illogical and someone has to be pretty crazy to consider it? - Do you tend to overact to a person with suicidal ideation? What is your philosophy on suicide? • Suicide is wrong - Suicide does violence to the dignity of life - Suicide adversely affects the survivors - Suicide is no different than homicide • Suicide is sometimes permissible - When alternatives are unbearable, eg. incurable extreme physical pain • Suicide is not an ethical or a moral issue - Phenomenon of life just like any other, subject to study • Suicide is a positive response in certain conditions - Patient has the right to make any decision, provided it is based on logical thinking and rationality. This also applies to the decision of suicide • Suicide has intrinsic positive value - Suicide has positive value because it re-unites a person with loved ones and their ancestors Some personal questions to help you reflect on your philosophy… • Do I know anyone in my family or friends who killed themselves? If so, what did I feel about it? Did I feel it was wrong? What I interview patients with suicide do I have images of those friends or family members? • Have I ever thought of taking my own life? • Under what circumstances, if any, do I picture myself as considering suicide as an option? • If a significant other like my child or parent killed themselves, how would my life be different? • What will I say if a patient asks me, “Do you believe it is ok to kill yourself?” Interviewing skills BASIC ESSENTIAL : Active VIDEO Listening • Ensure confidentiality to build trust; unless harm to self/others indicated • Rapport ▫ Ensuring a safe environment: • Carry out the interview in a quiet setting were possible • The interview should be unhurried and non-challenging ▫ Utilizing a good therapeutic approach: • Demonstrate acceptance of the patient/client • Acknowledge the current problem • Introduce yourself by name • Explain the purpose of the interview • Give assurance of confidentiality • Ask permission to take notes • Maintain eye contact as much as possible • Empathic support - Ask yourself “how would I feel if this happened to me?” - Acknowledging distress: • “I can see that things have been very difficult for you lately.” • “I can’t imagine how you must be feeling but I can see that it is very distressing for you.” Improving hopefulness: • “I can understand that you feel your situation is hopeless but with support we can help you through this.” • “Things haven’t gone so well for you lately but we can find a way through this.” Bolstering self-esteem: • “Coming here today must have taken a lot of courage.” • “Thank you for confiding in me.” Non-verbal communication: • Show that you are listening by nodding, saying ‘uh huh’ and maintaining eye contact. Reflect and paraphrase: • “You have told me that… and I can see that…” Questioning Techniques • Start off with open, indirect questions • Do not restrict the interview with direct, yes/no questions since these may stop further disclosure • Listen more than question but remember, you do need to ask questions • Silence is golden; long pauses help a person reflect • Once the person talks about specific problems ask ‘directive’ questions to clarify their meaning • Ask ‘directive’ questions when determining suicidal intent and the degree and seriousness of that intent • Importance of validity techniques – to overcome the barriers - Do not ask “why” questions; instead ask for details - Non-accusatory style; unconditional positive regard - Gentle assumption - Amplifying the symptoms - Denial of the specific; no cannon questions - Normalization The Specific Suicidal Inquiry – asking the uncomfortable questions • Suicidal Ideation • Plan • Means • Access to Means • Time Frame • Obstacles to execution of the act Jacobs DG, ed. The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco, CA. Jossey-Bass Publisher, 1998. Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. American Journal of Psychiatry (Suppl.) Vol. 160, No. 11, November 2003 • Suicidal Ideation (Passive) “Do you sometimes feel that life is not worth living?” “Do you think a lot about death?” “Do you sometimes think that if you die tomorrow from an accident or illness that it just wouldn’t matter?” • Suicidal Ideation (Active) “Have you had thoughts of killing yourself?” • Plan “Have you thought of how to do it?” “Have you thought of how to die?” “Have you thought of how to kill yourself?” • Means “What are you going to do?” (Charcoal Burning, Jumping, Overdose of Drugs &/or Medications, Suffocation, Poison, Cutting, Throwing self in front of car / train, Drowning) • Access to Means “How are you going to do it? (jump / overdose/cut/poison/burn)” • Ask why client has not acted on the impulse to commit suicide can provide an indicator as the level of danger “You have been talking about dying but you haven’t acted on itwhat stopped you?” “What enable to keep living?” “Why do you want to live?” Rating severity of risk Non-existent Mild Moderate Severe Extreme No identifiable suicidal ideation Suicidal ideation of limited frequency, intensity, and duration, no identifiable plans, no intent, mild dysphoria, good self-control, few risk factors, and identifiable protective factors Frequent suicidal ideation with limited intensity and duration, some specific plans, no intent, limited dysphoria, some risk factors present, identifiable protective factors Frequent, intense, and enduring suicidal ideation, specific plans, no subjective intent but some objective markers of intent (e.g., choice of lethal method, accessibility of means etc.), evidence impaired self-control, severe dysphoria, multiple risk factors present, few if any protective factors Frequent, intense, and enduring suicidal ideation, specific plans, clear subjective and objective intent, impaired self-control, severe dysphoria, many risk factors, no protective factors Baseline Absence of an acute over overlay, no significant stressors nor prominent symptomatology. Only appropriate for ideators and single attempt. Chronic high risk Baseline risk for multiple attempters. Absence of an acute overlay, no significant stressors nor prominent symptomatology. Acute Presence of acute overlay, significant stressors and/or prominent symptomatology. Only appropriate for ideators and single attempters. Chronic high risk & acute exacerbation Acute risk category for multiple attempters. Presence of acute overlay, significant stressors and/or prominent symptomatology. Risk monitoring card None 1. Predisposing Factors 2. Recent Stressors 3. Symptomatic presentation 4. Level of Hopelessness 5. Nature of Suicidal Ideation 6. Past attempts 7. Impulsivity 8. Protective Factors Mild Moderate Severe Extreme What to do next? • Severe and Extreme Risk= Immediate evaluation for psychiatric hospitalization. Client should be accompanied and monitored at all times, with active involvement of family members or police as warranted by the situation • Moderate Risk = Recurrent evaluation of the need for hospitalization. Frequent out-patient visits, address stressors, and symptom Family involvement 24-hour availability or emergency or crisis services Frequent risk assessment Consideration of medication – refer to psychiatrist Telephone contacts for monitoring purposes Frequent input from family members with respect to risk indicators • Mild / Non-existent risk = Recurrent risk assessment as indicated by circumstances and clinical presentation of patient When to document • At first/initial assessment or admission • With occurrence of any suicidal behavior or ideation • Whenever there is any noteworthy clinical change • For inpatients: - Before increasing privileges/giving passes - Before discharge CASE SCENARIOS ASSESS FOR SUICIDAL IDEATION AND BEHAVIOR ASSESS FOR THE LEVEL OF RISK WHAT WILL YOU DO NEXT? Professional Suicidal Person What went well What didn’t go so well What could be done differently Observer Thank you