Caring for Patients with Suicide Risk: Building a Foundation for Assessment, Screening, and Treatment

Question 1

Research has shown that most adolescent suicides occur when and where?

Answer 1

after school hours and in the teen’s home

Question 2

Most adolescent suicide attempts are precipitated by ___________ __________. The intent of the behavior appears to be to effect change in the behaviors or attitudes of others.

Answer 2

interpersonal conflicts

Question 3

Approximately 90% of those who complete suicide suffer from at least one major psychiatric disorder

1. WHat are consistently the most prevalent disorder (49-64%)
2. The 2nd most frequent diagnosis is a what?

Answer 3

1. Mood disorders

2. Substance abuse disorder.

Question 4

Here’s an Easy-to-Remember Mnemonic for the Warning Signs of Suicide: IS PATH WARM?

Describe each sign.

Answer 4

Ideation:
Expressed or communicated ideation threatening to hurt or kill him/herself, or talking of wanting to hurt or kill him/herself; and/or looking for ways to kill him/herself by seeking access to firearms, available pills, or other means; and/or talking or writing about death, dying or suicide, when these actions are out of the ordinary.

Substance Abuse:
Increased alcohol or drug use

Purposelessness:
No reason for living; no sense of purpose in life, start giving things away because there’s no purpose in keeping anything, no reason to maintain their hygiene

Anxiety:
Anxiety, agitation, unable to sleep or sleeping all the time, difficulty concentrating

Trapped:
Feeling trapped (like there’s no way out and things will never get better)

Hopelessness:
No future orientation

Withdrawal:
Withdrawal from friends, isolating from family and society

Anger:
Rage, uncontrolled anger, seeking revenge, irritable

Recklessness:
Acting reckless or engaging in high risk activities, seemingly without thinking, impulsive behavior (especially in younger people)

Mood change:
Dramatic mood changes, flat affect, depressed mood, acting out of character

Question 5

What does QPR stand for?

Answer 5

Question
Persuade
Refer

Question 6

QPR: Direct Verbal Clues?

5

Answer 6

1. “I’ve decided to kill myself.”
2. “I wish I were dead.”
3. “I’m going to commit suicide.”
4. “I’m going to end it all.”
5. “If (such and such) doesn’t happen, I’ll kill myself.”

Question 7

QPR: Indirect Verbal Clues?

5

Answer 7

1. “I’m tired of life, I just can’t go on.”
2. “My family would be better off without me.” “Who cares if I’m dead anyway.”
3. “I just want out.”
4. “I won’t be around much longer.”
5. “Pretty soon you won’t have to worry about me.”

Question 8

QPR: Behavioral Clues?

8

Answer 8

1. Any previous suicide attempt
2. Acquiring a gun or stockpiling pills
3. Co-occurring depression, moodiness,
   hopelessness
4. Putting personal affairs in order
5. Giving away prized possessions
6. Sudden interest or disinterest in religion
7. Drug or alcohol abuse, or relapse after a period
   of recovery
8. Unexplained anger, aggression and irritability

Question 9

QPR: Situational Clues?

9

Answer 9

1. Being fired or being expelled from school
2. A recent unwanted move
3. Loss of any major relationship
4. Death of a spouse, child, or best friend, especially if by
   suicide
5. Diagnosis of a serious or terminal illness
6. Sudden unexpected loss of freedom/fear of punishment
7. Anticipated loss of financial security
8. Loss of a cherished therapist, counselor, teacher, or pet
9. Fear of becoming a burden to others

Question 10

QPR: Tips for asking the suicide question?

6

Answer 10

1. If in doubt, don’t wait, ask the question
2. If the person is reluctant, be persistent
3. Talk to the person alone in a private setting
4. Allow the person to talk freely
5. Give yourself plenty of time
6. Have your resources handy; QPR Card, phone
   numbers, counselor’s name and any other information that might help

Question 11

QPR: Less Direct Approach?

4

Answer 11

1. “Have you been unhappy lately? “
2. “Have you been very unhappy lately?”
3. “Have you been so very unhappy lately that you’ve been thinking about ending your life?”
4. “Do you ever wish you could go to sleep and never wake up?”

Question 12

QPR: Direct Approach?

3

Answer 12

1. “You know, when people are as upset as you seem to be, they sometimes wish they were dead. I’m wondering if you’re feeling that way, too?”
2. “You look pretty miserable, I wonder if you’re thinking about suicide?”
3. “Are you thinking about killing yourself?”

Question 13

QPR: Persuade?

Answer 13

1. “Will you go with me to get help?”
2. “Will you let me help you get help?”
3. “Will you promise me not to kill yourself
   until we’ve found some help?”

Question 14

QPR: Refer?

4

Answer 14

1. Suicidal people often believe they cannot be helped, so
   you may have to do more.
2. The best referral involves taking the person directly to someone who can help.
3. The next best referral is getting a commitment from them to accept help, then making the arrangements to get that help.
4. The third best referral is to give referral information and try to get a good faith commitment not to complete or attempt suicide. Any willingness to accept help at some time, even if in the future, is a good outcome.

Question 15

The strongest predictor of suicide is a what?

Answer 15

previous attempt

Question 16

Suicide Risk factors: The Big Four?

Answer 16

1. Past Suicide Attempt
2. Diagnosis of mood disorder
3. Increasing use/abuse of alcohol or drugs
4. History of self-harm (e.g. cutting)

Question 17

Signs specific to Adolescents

4

Answer 17

1. Volatile mood swings or sudden change in personality
2. Indications that they are in unhealthy, destructive, or
   abusive relationships
3. Sudden deterioration in hygiene
4. Self-mutilation

Question 18

Signs specific to Adolescents

4

Answer 18

1. Fixation with death (poems, letters, chat rooms)
2. Eating disorders, especially combined with dramatic
   shifts in weight
3. Gender identity issues
4. Depression

Question 19

Signs specific to the Elderly

9

Answer 19

1. Stockpiling medications
2. Buying a gun
3. Giving away money or possessions or sense of urgency to settle estate or finalize will.
4. Taken sudden interest or loss of interest in religion.
5. Failure to care for themselves in terms of the routine activities of daily living.
6. Withdrawing from relationships
7. Experiencing failure to thrive, even after appropriate
   medical treatment
8. Scheduling a medical appointment for vague symptoms.
9. Chronic issues of pain management Undiagnosed depression

Question 20

Depression in the elderly
Before a diagnosis of depression is made, screen for some common health issues that can affect mood, including?
12

Answer 20

1. Alzheimer’s
2. Thyroid disorders
3. Multiple Sclerosis
4. Heart attack
5. Stroke
6. Parkinson’s disease
7. Cancer
8. Diabetes
9. Hormonal imbalances
10. Vitamin B12 deficiency
11. Electrolyte imbalances or dehydration
12. Some Viral Infections

Question 21

Depression in the Elderly: The following medications may cause symptoms of depression? 4

Answer 21

The following medications may cause symptoms of depression:

1. blood pressure medication
2. arthritis medication
3. hormones
4. steroids

Question 22

Specific medications that are currently being
investigated for their role in possibly causing
suicidal ideations:
5

Answer 22

1. Anticonvulsives such as Depakote, Lyrica, and Neurontin.
2. Smoking cessation medication Chantix.
3. Allergy medication Singulair.
4. Acne medication Accutane
5. Antidepressants (SSRI’s) when used with young people.

Question 23

Suicide Inquiry: Questions?

Answer 23

1. Thoughts of suicide
2. Plan
3. Intent
4. Access to Lethal Means

Question 24

The SLUMS is a 1.___-point, 2.___ question screening questionnaire that tests what? 4

Answer 24

1. 30
2. 11
3. • orientation,
   • memory,
   • attention, and
   • executive function

Dementia and cognitive function

Question 25

Protective factors that may mitigate suicide attempts?

Answer 25

1. Effective and appropriate CLINICAL CARE*** for mental, physical, and substance abuse disorders (depression is the one of the most treatable of all psychiatric disorders)
2. Easy access to a variety of CLINICAL INTERVENTIONS and support for help seeking
3. RESTRICTED ACCESS to highly lethal methods of suicide
4. Family and community SUPPORT
5. Support from ongoing medical, mental health
   and substance abuse CARE RELATIONSHIPS
6. Learned SKILLS in problem solving, conflict
   resolution, and nonviolent handling of disputes
7. CULTURAL and RELIGIOUS beliefs that discourage suicide and support self-preservation instincts

Question 26

PCP Intervention

Answer 26

1. Utilizing friends and family members that can be contacted in order to distract from suicidal thoughts.
2. Contacting health professionals or agencies, including 911 and the 1-800-273-TALK or going to the emergency room.
3. Reducing the potential for use of lethal means.
4. Encourage a support network
5. Help patient develop a pre-determined list of supportive individuals and their contact information. The network may include friends, family, clergy/minister, co-workers, therapist, suicide lifeline number.
6. Encourage patient to utilize network even when they are not a critical level.
7. Practice Coping Strategies
   - Patients who are familiar with their own triggers and cues can utilize coping strategies and may be able to prevent themselves from reaching a point where they feel out of control.
8. Practice Coping Strategies
   - Questions to help patient identify triggers
9. SAFETY PLAN
10. Documentation and followup care
11. Developing an office protocol for hospitalization

Question 27

a

Answer 27

a

Question 28

Office Protocol: Questions to answer in developing your office protocol are?

Answer 28

1) What are the laws in your state regarding involuntary admission?
2) Where will all necessary forms for hospitalizing suicidal patients be kept?
3) What psychiatric units are closest?
4) Is there a mental health provider in your area?

Question 29

If someone has major depression disorder how much greater risk are they at for suicide?

Answer 29

25%

Question 30

Four factors that help determine the seriousness of the suicide plan? 4

Answer 30

1. Specificity- details
2. Lethality
3. Availability
4. Proximity

Question 31

Four factors to access the current level of risk?

Answer 31

1. Dangerousness
2. Intent
3. Rescue
4. Timing

Question 32

If unable to act on a crisis when will the crisis subside naturally?

Answer 32

72 hours (72 hour hold)

Question 33

For a tentative diagnosis of depression?
4

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Answer 33

1. Questions 1 or 2 are endorsed in the shaded area.
   If there are at least 4 checks in the shaded section (including
2. Questions #1 and #2), consider a depressive disorder.
3. if there are at least 5 checks in the shaded section (one of which corresponds to Question #1 or #2), consider Major Depressive Disorder (a dx of MDD indicates 25x the risk of suicide.)
4. Shaded response to question #9 indicates 10x the risk of suicide

SLIDE 84

Question 34

Interpretation of Total Score
Total Score Depression Severity
5

SLIDE 85

Answer 34

1. 1-4 Minimal depression
2. 5-9 Mild depression
3. 10-14 Moderate depression
4. 15-19 Moderately severe depression
5. 20-27 Severe depression

SLIDE 85

Question 35

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up: Ideation Severity Subscale
4

SLIDE 86

Answer 35

1. Questions 1-5: Five types of ideation of increasing severity
   Score presence/absence of any suicidal ideation yes/no
2. Questions 1 and 2 are screening questions; if the answers to both are “no”, you do not need to ask questions 3-5 and may skip to the “suicidal behavior” section.
3. The most severe ideation endorsed (1-5) becomes the score for this section.
4. Bottom section provides history, presenting symptoms, and stressors.

SLIDE 86

Question 36

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up: Intensity of Ideation Subscale (Referring only to the most severe ideation endorsed above for the timeframe of interest)?

SLIDE87

Answer 36

1. Add the highest numbers endorsed on the 5 intensity items (Frequency, Duration, Controllability, Deterrents, and Reasons for Ideation).
2. The sum ranges from 2 to 25, with the higher number indicating more intense ideation.
3. If no ideation was endorsed on the Severity Subscale, assign a score of 0 or N/A for the Intensity Subscale.

SLIDE 87

Question 37

There are no “cut off” score for intensity. That said, we do have the following data that looked at ranges of scores and risk ratios for suicide behavior and found a 34X increase for the 21-25 range with lower odds ratios as the score range drops. These scores are best used to help inform clinical judgment when there is uncertainty about disposition and to assess change over time.

SCORES and their associated risk of suicide? 4

Answer 37

1. Moderate (6-10) 11x
2. Mod. Severe (11-15) 13x
3. Severe (16-20) 19x
4. Very Severe (21-25) 34x

Question 38

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up:

1. High risk is described as? 2

Answer 38

1. • Suicidal ideation with intent or intent with plan in past month (C-SSRS Suicidal Ideation #4 or #5)
   • Suicidal behavior within past 3 months (C-SSRS Suicidal Behavior)

Question 39

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up: High risk triage?
2

Answer 39

High Risk Triage

1. Refer to Psychologist or Psychiatrist to evaluate for hospitalization
2. Place on Facility High Risk List

Question 40

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up
High risk possible interventions?
10

Answer 40

1. Assessment of patient’s medical stability
2. Observation Status
3. Elopement precautions
4. Body/belongings search
5. Pharmacological treatment
6. Family/significant-other engagement
7. Psychotherapy (CBT, DBT)
8. Psychoeducation (coping skills, stress management,
   symptom management, etc.)
9. Safety Plan
10. Telephone Follow-up upon discharge

Question 41

Safety needs to consider in the physical environment:
Assess the physical environment, focusing on limiting access to methods. The most common methods of suicide in hospitals are what? 3

Answer 41

hanging,
suffocation
jumping.

Question 42

If risk assessment is conducted in outpatient setting:

What precautions do we need to take for high risk pts?

Answer 42

1. Place individual in a room that is away from exits but close to staff where patient is observed at all times
2. Beware of elopement risk if patient is against admission AND/OR wanting to be alone to follow through with plans of suicide

Question 43

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up: Moderate described as? 3

Answer 43

1. Suicidal ideation WITHOUT plan, intent or behavior in past month (C-SSRS screen #2 or #3)
   Or
2. Suicidal behavior more than 3 months ago (C-SSRS Suicidal Behavior)
   Or
3. Multiple risk factors and few protective factors

Question 44

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up: Moderate Triage?

Answer 44

Refer to mental health professional to evaluate risk factors and determine appropriate treatment setting

Question 45

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up: Moderate possible interventions?
7

Answer 45

1. Pharmacological treatment
2. Psychotherapy (CBT, DBT)
3. Psychoeducation (coping skills, stress management, symptom management, etc.)
4. Engagement with family-member or significant-other
5. Safety Plan
6. Provide National Suicide
7. Prevention Lifeline card and local emergency contacts

Question 46

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up: Low risk described as? 4

Answer 46

1. Wish to die (C-SSRS Suicidal Ideation #1) no plan, intent or behavior
   Or
2. Suicidal ideation more than 1 month ago WITHOUT plan, intent or behavior (C-SSRS screen #2 or #3)
   Or
3. Modifiable risk factors and strong protective factors
   Or
4. No reported history of Suicidal Ideation or Behavior

Question 47

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up: Possible interventions for low risk? 3

Answer 47

1. Provide information about warning signs.
2. Provide National Suicide Prevention Lifeline card and local emergency contacts
3. Re-assess at treatment plan review

Question 48

Caring Contact Studies: Ideally, contacts would be made at the following intervals?
4

Answer 48

1. Within 3 days of visit
2. Once at two weeks
3. Once at 4 weeks
4. Once at 2 months and 3 months

Question 49

What is ASIST?

Answer 49

A two-day workshop designed to provide participants with gatekeeping knowledge and skills. Gatekeepers are taught to recognize the warning signs and to intervene with appropriate assistance.

Question 50

What is Mental Health First Aid?

Answer 50

Mental Health First Aid is a groundbreaking public education program that helps the public identify, understand, and respond to signs of mental illnesses and substance use disorders.

Question 51

Other Evidenced-Based Suicide Prevention Programs:

What is SOS: Signs of Suicide program?

Answer 51

School-based program which aims to raise awareness of suicide and reduce stigma of depression There is also a brief screening for depression and other factors associated with suicidal behavior.

Question 52

What is CIT?

Answer 52

Crisis Intervention Training
CIT came out of the Memphis Police Dept. and is a training for law enforcement officers to help them manage mental health issues when they respond to a call.