Suicide

Question 1

Suicide vs suicide attempt

Answer 1

1. Suicide is a death caused by self-directed injurious behavior with any intent to die as a result of the behavior.
2. Suicide Attempt is defined as a non-fatal self- directed and potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not result in injury.

Question 2

Overview of suicide 2017 including demographics (6)

Answer 2

1. True number for suicide may be lower than it seems as accidental injury may actually be suicide
   * Estimate that 2 million children attempt suicide each year
2. Certain groups higher rates—
   a. American Indian/Alaskan Native males have the highest suicide rate
   b. Black females have the lowest suicide rate
   c. LGBTQ sexual minority youth-twice the rate
   d. Males 15-19 are three times more likely to complete suicide attempt
   * Males use more lethal methods than females and are thus more successful
   e. Females are twice as likely to attempt suicide.
3. Uncommon in children before puberty but can occur at any age
   * Epidemiological data in prepubertal children is scarce; 0.5 per 100,000 females and 0.9 per 100,000 males 5-14 year old
4. Most individuals who die of suicide have visited a health care provider in the year before death, most within 3 months with a somatic concern
5. Second leading cause of death among 10-14 year old and 15-10 year olds

Question 3

Suicide: Fixed Risk Factors (10)

Answer 3

1. Family history of suicide or suicide attempt (major risk factor)
2. History of adoption
3. Male gender
4. Parental mental health problems
5. Lesbian, gay, bisexual or questioning sexual orientation
6. A history of physical or sexual abuse
7. Previous suicide attempt
8. Availability of lethal means
9. Personal mental health problems—sleep disturbance, depression, bipolar disorder, substance intoxication, substance disorder, psychosis, PTSD, panic attacks, history of aggression, impulsivity, severe anger, pathological Internet use
   * 70 fold increase in acute suicidal behavior in children with psychopathology
10. Nonsuicidal self-injury

Question 4

Suicide: immediate risk factors (3)

Answer 4

1. Agitation
2. Intoxication
3. Recent stressful life event

Question 5

Suicide: Social and environmental risk factors (6)

Answer 5

1. Bullying
2. Parent-child relationship
3. Living outside the home (homeless, corrections facility, group home)
4. Difficulties in school—neither working or attending school
5. Social isolation
6. Stressful life events—legal or romantic, argument with parent

Question 6

Risk Factors: Individual Level (7)

Answer 6

1. History of depression and other mental illnesses
2. Hopelessness
3. Substance abuse
4. Poor health
5. Previous suicide attempt,
6. Violence victimization and perpetration
7. Genetic and biological determinants

Question 7

Risk Factors: Relationship Level (4)

Answer 7

1. Conflict or violent relationships
2. Sense of isolation and lack of social support
3. Family/ loved one’s history of suicide,
4. Financial and work stress

Question 8

Risk Factors: Community Level (2)

Answer 8

1. Inadequate community connectedness,

2. Barriers to health care (e.g., lack of access to providers and medications)

Question 9

Risk Factors: Social Level (3)

Answer 9

1. Availability of lethal means of suicide
2. Unsafe media portrayals of suicide
3. Stigma associated with help-seeking and mental illness.

Question 10

Protective Factors Against Suicide at Younger Ages (7)

Answer 10

1. Access to mental health services
2. Positive connection in school
3. Family stability
4. Religious involvement
5. Lack of access to deadly weapons
6. Good relationship with peers
7. Ability to problem solve and over come adversity

Question 11

Suicide Assessment Five-step Evaluation and Triage (SAFE-T)

Answer 11

Circle of:
Identify risk factors –> identify protective factors –> conduct suicide inquiry –> determine risk level/intervention –> document

Question 12

Bullying as a Risk Factor (3)

Answer 12

1. Meta-analysis should a clear relationship between both bullying victimization and perpetration and suicidal ideation and behavior
2. Suicidal ideation and behaviors were highest in
3. Children at age 8 who had bullying behavior was associated with later suicide attempts

Question 13

Suicide interviewing (3)

Answer 13

1. Asking about mood disorders, thoughts of suicide, and substance abuse/dependence
2. Asking about bullying
3. Internet use that exceeds 5 hours per day
   a. Suicide-related searches
   b. Online suicide pacts
   c. Prosuicide websites

Question 14

Evidence Based Screening Tools: Overview (4)

Answer 14

1. Brief standardized tools: Identify children needing evaluation.
2. Not perfect
3. Studies have identified that children initially identified to have a positive developmental or behavioral screen that are not found to be eligible for services are at high risk and need closer monitoring than children who initially screened negative.
4. In young child, use parent screens
   a. Identify parents’ concerns
   b. Obtain developmental behavioral history
   c. Identify developmental and behavioral risk factors
   d. Identify protective factors

Question 15

Ask Suicide Screening Questions Tool Age

Answer 15

10-21 years old

Question 16

Risk for suicide questionnaire age

Answer 16

8-18 years old

Question 17

columbia suicide severity scale age

Answer 17

7+

Question 18

treatment emergent activation and suicidality assessment profile age

Answer 18

7-17 years old

Question 19

mood and feeling questionnaire age

Answer 19

7-17 years old

Question 20

patient health questionnaire-adolescent version age

Answer 20

12-18 years old

Question 21

Ask Suicide‐Screening Questions (ASQ) (5)

Answer 21

1. Developed from 17 questions among 524 ED patients
2. High negative predictive value (NPV) of 99.7% for med/surg patients and 96.9% with psychiatric patients
3. Positive predictive value (PPV) is71.3%for psychiatric patients but only 39.4% for med/surg patient
4. Questions:
   a. In the past few weeks, have you felt that you or your family would be better off if you were dead?
   b. In the past few weeks, have you wished you were dead?
   c. In the past week, have you been having thoughts about killing yourself?
   d. Have your ever tried to kill yourself?
5. Use ASQ rather than developing your own questions

Question 22

Risk For Suicide Questionnaire (5)

Answer 22

1. Also composed of 4 questions
2. Normed on patients 8 to 18 year presenting for psychiatric complaints
3. PPV of 55%, NPV of 97%
4. Sensitivity of 97% and specificity of 37%
5. Questions
   a. Are you here today because you have tried to hurt yourself
   b. In the past week, have you been having thought about killing yourself?
   c. Have you ever tried to hurt yourself in the past (other than this time)
   d. Has something very stressful happened to you in the past few weeks (a situation very hard to handle)?

Question 23

Treatment Emergent Activation and Suicidality Assessment Profile TESSAP (4)

Answer 23

1. 38 item questionnaire, parent report
2. Psychometrics are good in an initial study
3. Not used as much clinically
4. Research after the initial work lacking

Question 24

Mood and Feeling Questionnaire (MFQ) ‐ Suicide Ideation (8)

Answer 24

1. Hammerton used the MFQ 4 items for suicidal ideation Sensitivity of 57%, specificity of 57%
   * *2. Low Positive predictive value of 10% and NPV of 97%
2. I thought that life was not worth living
3. I thought about death or dying
4. I thought family would be better off without self I thought about killing self
5. 1. If a sentence was not true about you, check NOT TRUE. (0)
6. 2. If a sentence was only sometimes true, check SOMETIMES. (1)
7. 3. If a sentence was true about you most of the time, check TRUE. (2)

Question 25

Columbia Suicide Severity Rating Scale (C-SSRS) (4)

Answer 25

1. 17 item scale that helps to determine between suicidal ideation and suicidal behavior
   a. 2 question to assess suicidal ideation
   b. 4 designed to detect suicidal behavior
   c. Sensitivity and specificity in studies range from 93% to 100%
2. 7-17 years of age
3. Measures four subscales
   a. Severity
   b. Intensity
   c. Behavior
   d. Lethality
4. Gives you much more information; goes into more details about planning, etc

Question 26

Suicide inquiry: definition of ideation, plan, behaviors and intents

Answer 26

1. Ideation: Frequency, intensity, duration in last 48 hours, past month and worst ever
2. Plan: Timing, location, lethality, availability, preparatory acts
3. Behaviors: Past attempts, aborted attempts, rehearsals versus non-suicidal self- injurious actions
4. Intents: Extent to which the patient
   i. Expects to carry out the plan
   ii. Believes the plan/act to be lethal versus self-injurious
   iii. Explores ambivalence—reasons to die vs. reasons to live

Question 27

Depression and Suicide: Patient Health Questionnaire‐A (4)

Answer 27

1. Designed for use in pediatric patient populations for ages 12 to 18
   a. PHQ-9 Modified for Teens differs from the original PHQ-9 in that it includes 4 additional questions –
   i. 2 that inquire about severity of symptoms
   ii. 2 questions to determine suicide risk
2. Less than 5 minutes to administer and score
3. One page questionnaire
4. 10 questions

Question 28

What does the research show? (4)

Answer 28

1. Patients 10-21 years of age presenting to ED
2. Screened 524 patients with the Suicidal Ideation Questionnaire to develop the shorter Ask Suicide Screening Questions (ASQ)
3. 11.5% reported bully victimization, of those 55% screened positive for suicide risk
4. Implications for identifying patients at greater risk earlier to prevent suicide attempts.

Question 29

Suicide Identification in the ED (10)

Answer 29

1. 79% of patients were screened by nursing staff
2. Nurses were more likely to screen females, patients who had suicide related chief complaints, or patients who had emergency requests for mental health evaluations
3. Less likely to screen those with internalizing symptoms, alcohol or drug overdoses, bizarre behaviors, or hallucinations
4. Of the patients with a psychiatric complaint over half screened positive—positive screening were less likely in patients with externalizing behavior or with an emergency request for psychiatric evaluations
5. Prevention opportunity was missed 21% of the time
6. ASQ could be incorporated into the initial screening of the patient
7. Nurses felt sympathetic toward the patient but were uncertain about how to manage them
8. May not be able to screen patients in triage who initially presents with alcohol or substance abuse but this should be done before they leave the ED
9. Indicates that many more patients have suicidal thoughts than report suicidal behavior as a presenting complaint.
10. Suicidal ideation may be a better predictor of later suicidal behavior in adolescent females

Question 30

Reasons why screening is not done (4)

Answer 30

1. Time constraints
2. Inadequate training—Lack of comfort in asking about mental health problems
3. Lack of proper screening instruments
4. Lack of resources to treat children

Question 31

Child and Adolescents Broad Band Screening (5)

Answer 31

1. Goal is to pick up any possible mental health disorder
2. SHEADS: I’MVeryGood
3. KySS Assessment Questions for Specific Emotional or Behavioral Problems
4. Pediatric Screening Checklist(PSC)
5. Strengths and Difficulties Questionnaire

Question 32

KySS Mental Health History Screener (3)

Answer 32

1. KySS Assessment Questions for Parents of Older Infants and Toddlers
2. KySS Assessment Questions for parents of Preschool Children
   a. Can be available for younger groups
3. KySS Assessment Questions for Parents of School-Age Children and Teens

Question 33

Pediatric Symptom Checklist (7)

Answer 33

1. PSC is a screening instrument
2. Alert clinicians early to difficulties in functioning that may indicate current or potential psychosocial problems.
   a. Can intervene earlier and thus to prevent some premorbid childhood conditions from becoming more serious
   b. Takes under 5 minutes to complete and is free
   c. Each item is rated as often, sometimes, or never (2,1,0)
3. For children ages 4 to 18 years
4. Screens for both externalizing and internalizing behaviors
5. 35 short statements of problem behaviors
6. Ratings assigned values as follows: never (0), sometimes (1), always (2)
7. Score > 28 suggests a referral
   a. 3 subscale scores
   i. Attention
   ii. Externalizing disorder with acting out symptoms—conduct disorder
   iii. Internalizing disorder with quieter symptoms-depression anxiety

Question 34

Broad Band Screener (4)

Answer 34

1. PSC-35-full –> Parent-administered: available in 19 languages
   * Youth self-administered: available in 6 languages
   * Pictorial version: available in 3 languages (subtitles)
2. PSC-17-Abbreviated
   a. Parent-administered: available in 4 languages
   b. Youth self-administered: in 2 languages
3. Parent-Reported and Youth Self-Reported
   a. Parent version can be used for children 4 and over
   b. Asks about a variety of topics including school functioning, physical complaints, and mood
4. General psychosocial screen
   a. AAP endorses PSC for ages 4-16

Question 35

Strengths and Difficulties Questionnaire (SDQ) (3 with info)

Answer 35

1. Children between 2 and 17 years of age
2. Measures social, emotional, and behavioral functioning (see appendix)
   a. 25 questions
   b. 5 sub scales
   i. Emotional symptoms
   ii. Conduct problems
   iii. Hyperactivity/inattention
   iv. Peer relationship problems
   v. Prosocial behavior
3. Youth in Mind

Question 36

Screening for Trauma, PTSD, and Adverse Childhood Events (4)

Answer 36

1. Childhood Trauma Questionnaire
   * Free, 10 question self reported survey looking for emotional, physical, & sexual abuse as well as emotional & physical neglect
2. Adverse Childhood Experience (ACE) Questionnaire
   * Free, 10 question self-reported survey
3. CATS Trauma screen
   * Available for parent/child
4. SCARED PTSD

Question 37

High Risk Level: Risk/Protective Factors, Suicidality, Possible Interventions

Answer 37

Risk/Protective Factors: psychiatric diagnosis with severe symptoms or acute precipitating event; protective factors aren’t relevant

Suicidality: potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal

Possible Interventions: admission generally indicated unless a significant change reduced risk; needs suicide precautions

Question 38

Moderate Risk Level: Risk/Protective Factors, Suicidality, Possible Interventions

Answer 38

Risk/Protective Factors: multiple risk factors with few protective factors

Suicidality: suicidal ideation with plan, but no intent or behavior

Possible Interventions: admission may be needed depending on risk factors; develop crisis plan and give local/national emergency info

Question 39

Low Risk Level: Risk/Protective Factors, Suicidality, Possible Interventions

Answer 39

Risk/Protective Factors: modifiable risk factors, strong protective factors

Suicidality: thoughts of death with no plan and no intent or behavior

Possible Interventions: outpatient referral; symptom reduction plan; give local/national emergency information

Question 40

Teach back method (5)

Answer 40

1. A method for ensuring understanding in a non- shaming way
2. Asking patients to explain in their own words what they need to know or do
3. An indication of how well YOU communicated the information, NOT a “test” of the patient
4. A chance to check for understanding and, if necessary, re-explain and check again
5. An evidence-based approach to improving patient-provider communication and patient health outcomes

Question 41

Use of teach back method (3)

Answer 41

1. Communication confirmation method
   i. I want to be sure I explained everything clearly. Can you explain it back to me so I can be sure I did?
   ii. What will you tell your partner about the changes we made to your medicines today?
   iii. We’ve gone over a lot of information. Can you tell me what we talked about?
2. Confirms whether a patient (or care takers) understands what is being explained to them.
3. If a patient understands, they are able to “teach- back” the information accurately.

Question 42

Prevention of suicide (9)

Answer 42

1. Need to use strategies to screen youth for suicide risk that are tailored to the child’s developmental level
2. Should be screening for suicide in all medical settings including but not exclusively the ED
3. Use instruments that were developed and tested for suicide risk detection and were developed specially for youth
4. Address hopelessness and develop reason for living
5. Monitor mood
6. Reduce negative emotions
7. Development of Safety plans
8. Use cognitive behavioral therapy
   a. Use of Cognitive Behavior Therapy for
   b. Suicide prevention as a treatment model in patients with repeated suicide attempts
   i. Develop a more effective coping when faced with problems/stressor that trigger suicide risk reduction strategies
9. Come up with alternate positive thoughts “I can do this”
   a. Have to develop a plan around these thoughts

Question 43

Safety Planning and Suicide Prevention: Internal strategies

Answer 43

List of behavioral activities to do to distract patient from thinking about suicide

Question 44

Safety Planning and Suicide Prevention: External strategies (4)

Answer 44

1. Help from family members and friends
2. List of community resources should be made available to families
3. Help lines
4. Emergency hospitalization