Suicide Risk Assessment and Management in the Medical Hospital - PowerPoint Presentation

1. Suicide Risk Assessment and Management in the Medical HospitalAPM Resident Education CurriculumAnn Schwartz, MD, FAPMAssociate ProfessorChief, Consultation Liaison Service, Grady Memorial HospitalDepartment of Psychiatry and Behavioral SciencesEmory University School of MedicineUpdatedFall 2013Ann Schwartz, MDKristi Estabrook, MD

2. SuicideDefinitionsEpidemiologyClinical assessment of suicide riskSuicide risk assessment / documentationChallenges2

3. Suicide“The termination of an individual’s life resulting directly or indirectly from a positive or negative act of the victim himself which he knows will produce this fatal result”Durkheim 18573

4. EpidemiologySuicide is the 11th leading cause of death in the US30,000 deaths/yearAccounts for 1 – 2% of all deathsKnown suicide rate is nearly identical to rate in 190010-12/ 100,000/ yearFirearms most common method (60- 65%)Regional variationHanging second most common for men, drug overdose second most common for womenFor each person that completes suicide, ~8-10 people attemptFor every completed suicide, ~18-20 attempts are made4

5. Suicide-Related BehaviorsPotentially self injurious behaviorsSuicideInstrumental suicide-related behaviorsFocus on intent to die“The person intended at some (non-zero) level to kill self….”“The person wished to use the appearance of intending to kill self in order to obtain some other end…”5

6. “The person intended at some (non-zero) level to kill self….”Suicide, completed suicideSuicide attempt with injuriesSuicide attemptSuicidal act6

7. “The person wished to use the appearance of intending to kill self in order to obtain some other end…”Parasuicidal actsGesturalSelf-injuriousManipulative, dyadic, reactive, relational7

8. Suicide IntentKnowledge of lethality of methodCognitive capacity of victimUse of high lethality methodCertain lethal vs. potentialPlanned, organized, persistentMultiple potential stopping pointsActive measures of non discovery/ preventionActive evasion vs. active discovery8

9. Case 1HPI38 yo AAF with hx of depressionAdmitted to medicine after overdose on sleeping agentPrecipitant to attempt identified as feeling lonely2-3 week hx of worsening depressive symptomsDaughter (3 yo) died ~5 years agoPAST PSYCH HX:1 prior suicide attempt by OD after daughter’s death1 previous psych admission after ODPAST MEDICAL HX:HTN9SOCIAL HX:Single, lives aloneMany friendsHas graduate degree and works as a bankerFinancial difficulties (bought car that she can’t afford)Social ETOH, increased use recentlyDenies drug useFAMILY HX:Parents deceasedFather with completed suicide when pt was 8Mother died of CA when pt was 16

10. Case 1Mental Status ExamThin, AAF who appeared her stated ageAlert, cooperative, but tearful throughout interviewSpeech was normal rate, tone, and volumeMood was depressed, affect restricted but congruent with moodThoughts were linear and focused on wanting to leave and return to workNo overt delusions, denied AH/VHDenied current SI/HIFuture-oriented behavior10

11. Case 1 Questions:Risk and protective factors for suicide?ModifiableModifiable by treatmentNon modifiableRisk factors potentially modified by inpatient psychiatric admission?Precautions while hospitalized medically?Disposition?Inpatient psychiatric admission Outpatient 11

12. Suicide AssessmentThrough clinical evaluation, identify specific factors that may increase or decrease risk for suicide and suicidal behaviors that may serve as modifiable targets for interventionsAddress patients immediate safety and determine most appropriate setting for treatmentDevelop differential diagnosis to further guide planning of treatment12

13. SuicideNot a diagnosisNot limited to depressionSchizophreniaBipolarSubstance use disordersImpulse control disordersNot limited to “official” psychiatric disordersStates of desperation or despairImpulsive, aggressive, disinhibited13

14. SuicideBehavioral phenotypeLow base-rate eventRareHard to predictFalse positiveCostly treatment decisionsFalse negativeImpact on family, practitioner and staffLegal liability14

15. Epidemiology____________________________________________________________Relationship between SI, attempts, and completed suicide155.6% incidence of suicidal ideation per year0.7% incidence of suicide attempts per year0.01% will complete suicide per year

16. Risk Factors for SuicideDemographicPsychiatricMedical SocialFamilialPast and present suicidalityTreatment settingsStatus as medical inpatient16

17. Non Modifiable Risk FactorsGenderMale> femaleRaceWhite> Non white minorityAgeOld> youngPast behaviorsSuicide attemptsFamily history complete suicide17

18. Modifiable Risk FactorsPotentially modifiableTreatmentOther processMental statusCurrent suicidal ideationDepressionAnxietyHopelessness/ despairDesperationIntoxicationAccess to high lethality meansFirearm in homeRecent loss / setback18

19. Psychiatric Risk Factors90% with diagnosisDepression (MDE) common30-60% with a substance use disorderCombination mood episode plus substance use disorderMost suicides with psych and substance diagnosis, but most psych and substance patients do NOT die from suicide19

20. Observable High RiskAgitatedAnxiousPsychomotor activityEmotional labilityGlobal insomniaAppetitive disturbanceNihilistic distraction20

21. Observable High RiskHigh level distressDesperationIrritationAkathisiaMixed maniaAnxietyAlcohol intoxicated21

22. Observable Low RiskSomnolent, sleepy, sleepingCalmHungry, eatingSelf-directed actions“I want…”Future directed actionsManipulative or dyadic“If you don’t…..I will kill myself…”22

23. Substance Abuse & DependenceKnown risk factor for suicideCocaine significant impact on moodEtOH intoxicationDisinhibitingChronic EtOH useMood disorder23

24. Alcohol Use Preceding SuicideWhite > African American at all agesGender follows raceAll age groupsAverage blood level above legal (0.08) definition of intoxication24

25. Medical FactorsMedical illness, especially severe or chronic may be risk factor for completed suicideModifiable vs. non modifiableMedical disorders associated with as many as 35-40% of suicides25

26. Medical FactorsAIDSCancerHead TraumaEpilepsyMultiple sclerosisHuntington’s choreaOrganic brain syndromesSpinal cord injuries26HypertensionCardiopulmonary diseasePeptic ulcer diseaseChronic renal failureCushing’s diseaseRheumatoid arthritisPorphyria

27. Social Risk FactorsMarital status Social isolationFinancial difficultiesRecent loss / setbackUnemploymentLegal involvementAccess to high lethality meansFirearm in homePharmaceutical products27

28. Socioeconomic FactorsMacroeconomic forces impact suicide ratesEmploymentSingle parent householdsHousing availabilityAvailability of psychiatric resourcesLower SES might be associated with higher suicide risk28

29. Familial FactorsFamily history of suicideFamily history of psychiatric illnessEarly parental death or separationHistory of emotional, physical, or sexual abuse29

30. Past and Present SuicidalityPrior suicide attemptsNon modifiableSuicidal ideationPotentially modifiableSuicidal intentPotentially modifiableHopelessnessPotentially modifiable30

31. Suicide AttemptsSensitive but NOT specific measureNon-modifiable risk factor~10% of patients who make a medically serious suicide attempt ultimately dieIdentifies chronic high risk groupMales at higher riskUnclear distinction between eventual completers and “survivors”Unclear impact of treatment31

32. Treatment SettingsStatus as medical inpatient increases suicide riskParadox of psychiatric admissionMajor period of risk for completed suicide2 weeks post discharge from psych unitDischarge leads to instability vs. admission identifies enriched high risk sample32

33. Protective FactorsPotentially modifiableTreatment OtherRestricted access to lethal meansSkills in problem solving and conflict resolutionCultural and religious beliefs that discourage suicideStrong psychosocial supportsReasons for livingDependent children in home33

34. Case 247 yo WM with hx of HIV/AIDS and CHFAdmitted to medicine with chest painUDS, + cocaine Cardiac w/u essentially normalOn discharge, pt verbalized SIIrritable on interviewEndorsed irritability, insomnia, poor concentration, low energyFocused on finding place to stay and foodNo hx of mania or psychosis34PAST PSYCH HX:1 prior psychiatric admission for SI three years agoNo prior suicide attemptsPAST MEDICAL HX:HIV/AIDSCHFSOCIAL HX:Divorced, recently homeless1 daughter (strained relationship)Unemployed, no incomeCocaine use, amount unknown

35. Case 2Mental Status ExamAlert, disheveled, irritable, minimally cooperativePoor eye contactSpeech was soft, normal rateMood was irritable, affect reactiveThoughts were linear and focused on wanting housing and double portionsNo overt delusions+ AH - “telling me to kill myself,” denied VHEndorsed SI, vague plan of “smoking crack to blow up my heart”Denied HI35

36. Case 2 Questions:Risk and protective factors for suicide?ModifiableModifiable with treatmentNon modifiableRisk factors potentially modified by inpatient psychiatric admission?What other information would be helpful in determining risk?Disposition? Inpatient psychiatric admissionOutpatient 36

37. What Distinguishes Those Who Commit Suicide From Those Who Do NotThe risk states are very commonMental illnessSubstance use disordersLoss, illness, trauma etcThe outcome is relatively rare in comparison to the at risk populationPathophysiological mechanism for “rare” event in common backgroundBiology of suicide versus depression37

38. Suicide Risk AssessmentDocument formulation of individual risk and protective factorsDocument clinical reasoning and decision makingDocument interventions and follow upRisk factors modifiable with treatmentSafety plan38

39. Suicide Risk Assessment (Risk Factors)Document static risk factorsDocument dynamic risk factorsPsychiatric diagnosisAccess to firearmDocument mental statusExpressed suicidal ideationDocument Observable risk behaviorsAgitation, anxiety, lability, etc39

40. Suicide Risk Assessment (Protective Factors)Document protective factorsGender, family structureDocument low risk behaviorsSomnolent, sleeping, future-directed, etcDocument intentParasuicidal, gestural, manipulative40

41. Suicide Risk AssessmentDemographic characteristics impact riskNot modifiableDo impact decision makingHighest riskWhite maleLowest riskAfrican American femaleAge 45 and above (AAF)41

42. Suicide Risk AssessmentDocumentationDocument presence of firearm in homeDocument discussion with patient/ family/ support groupRemove weapon from homeSafekeepingMinimizing access to high lethality means has been shown to reduce suicide rates 42

43. Evaluation of Suicide RiskNonjudgmental and supportive approachEvaluate suicidal ideation and intentPresence of suicidal thoughtsDetails of suicide planSeriousness of intent (or attempt)Social supportsRisk/rescue ratioDegree of impulsivityAssess for presence of risk factorsPerform mental status examCollateral information43

44. Management of Suicide RiskStabilize medical conditionsSafe containmentPhysical or chemical restraintSupervision (1:1 sitter)Remove dangerous objectsRepeated observation / assessmentConsider initiation of treatment44

45. Management of Suicide RiskRemove or treat modifiable risk factorsPhysical or chemical restraintPsychotherapy (supportive)Communication with consultant about treatmentPsychiatric hospitalizationDispositionHome with outpatient follow upAdmission to medical unitVoluntary admission to inpt psychiatric unitInvoluntary admission to inpt psychiatric unit45

46. In Hospital PreventionTreat agitation, anxiety and depression immediately and aggressivelyCommunication with psychiatric and other treatment providersInpatientOutpatientEncourage family support and involvementEncourage staff communicationTreat pain aggressively“Safety-proof” patient roomsTrained 1:1 sitter46

47. Psychopharmacology and SuicideDecreasing suicide riskUse medications mainly to treat underlying mood disorders or acute distressLithium and Clozapine have been show to decrease risk of suicidePossible increased risk? SSRIs in certain populationsBlack box warning for SSRIs in pediatric populations and ages 18-24This is controversial with conflicting evidence47

48. ChallengesIntoxicated patientsThreatening patientsUncooperative patientsCountertransference issues49

49. Intoxicated PatientsCurrent intoxicationHold till sober (BAL= 0.08)ReassessSubstance useProximate risk factorTreatment implications?Does chemical dependency treatment modify risk?49

50. Threatening or Uncooperative PatientsSafety precautionsStaff trainingSecurityEfforts to establish rapportAggressive behavior is risk factorMove to “safest” areaCrisis stabilization unitLaw enforcement referral if indicated49

51. Countertransference IssuesAnxiety“Wrong” decision may have fatal consequencesAngerHave personal feelings toward suicidal patientsWith patients with multiple gestures“Frequent flyers”DenialMay conspire with patient that attempt was “just an accident”53

52. ConclusionsSuicide is the lethal outcome of mental illnessStress diathesis modelMood disorders, mental illnessDistress, desperationSuicide risk varies byAge, race, gender, other factorsModifiable and non-modifiableAccess to high lethality means (firearms) critical factorAdvise remove weapon from homeSecure pharmaceutical products53

53. ConclusionPsychiatrist not fortune tellersFuture difficult to predictSystematic Suicide Risk AssessmentOrganize dataGuide clinical decision makingDocument, document, document54

54. ReferencesBostwick JM: Suicidality, in The American Psychiatric Publishing Textbook of Consultation-Liaison Psychiatry, Second Edition. Edited by Wise MG, Rundell JR. Washington, DC, 2002, pp 127-148Busch KA, Fawcett J, Jacobs DG: Clinical correlates of inpatient suicide. J Clin Psychiatry 2003; 64(1):14-19O’Carroll PW, Berman AL, Maris DW, Moscicki EK, Tanney BL, Silverman MM: Beyond the Tower of Babel: a nomenclature for suicidology. Suicide Life Threat Behav 1996; 26 (3): 237-252Silverman MM, Berman AL, Sanddal ND, O’Carroll PW, Joiner TE: Rebuilding the tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors. Part 1: Background, rationale, and methodology. Suicide Life Threat Behav 2007; 37(3): 248-263Stern TA, Perlis RH, Lagomasino IT: Suicidal patients, in Massachusetts General Hospital Handbook of General Hospital Psychiatry, fifth edition. Edited by Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF. Philadelphia, PA, 2010, pp 541-55455