Suicide

Question 1

Suicide

Epidemiology

Answer 1

• 10^th leading cause of death in US
• Highest rate between 45‐54
• 2^nd highest in pts > 85 y/o
• Rates increasing last 10 years
• ~ 45k per year; 123 per day
• 51% by firearms; 26% by hanging
• ~ 500k hospital visits for self‐harm (approx. 2000 will die by suicide)
• 3.5 males: 1 female; 70% white men

Question 2

Attempters

Answer 2

• 60% of individuals die on first attempt
• 20% of survivors make another attempt within the year
• 1‐2% complete within the year; 4‐fold increase in rate
• 10‐15% eventually complete (80% in the first year)
• All inpatients have increased risk after discharge – first 3 months

Question 3

Suicide Risk in Primary Care Patients

Answer 3

• Higher risk in patients with coexisting physical and psychological illnesses
• 1.81x increased risk in ideation post CVA, 1.27 in osteoarthritis
• 3.88x increased risk of attempt with angina, 2.09 in osteoarthritis, 12 in TB, 4.92 in renal failure
• CA of lung and cervix raise odds of attempt more than 10x

Question 4

Suicide in Primary Care

Answer 4

• 50% of pts who suicide see PCP in the 4 weeks prior to death
  
  • ½ of these w/ a documented reason for the visit had a psychosocial complaint
  • 10% seen in ER 2 months prior to death
• 10-40% suicides seen by PCP the week before death; almost none discussed or asked about it
• 25% of pts in PCP practice have mental health disorder associated w/ suicide
• Only 30-50% of people in US who die by suicide are in some type of psychiatric treatment

Question 5

Identification of Suicide Risk

Answer 5

• Screen every patient at initial evaluation for risk factors for suicide w/ direct and specific questions
• Over the past two weeks have you had thoughts about wanting to die?
• (If yes) How often? Have you made any plans? Have you acted on any of these plans?
• At any other time in your life have you attempted to kill yourself?
• Do you have access to a gun?

Question 6

Who to ask about suicide?

Answer 6

• New pts
• Pts w/ current depression
• Pts w/ other mood disorders
• Pts w/ history of psychiatric hospitalization
• Pts w/ active substance abuse or dependence
• Pts w/ new dx of terminal illness
• Pts w/ antisocial or borderline personality
• Patient w/ significant psychosocial stressor

Question 7

Identification of Suicide Risk

Answer 7

• Demographic risk factors (static risk): age (45-64), race (90% caucasian), sex (73% men), family hx, h/o childhood sexual abuse
• Diagnostic risks: substance use, mood disorders, schizophrenia
• Psychosocial risk factors: Loss of relationship, legal, financial, work, health concerns
  
  • Highest risk 6-12 months after psychiatric hospitalization
• Cognitive risk factors: impulsivity/aggression, anxiety/agitation, hopelessness, rage, romanticize death, poor concentration, poor coping skills

Question 8

Adolescents

Answer 8

• 3^rd leading cause of death
• Females attempt > males, males more completion
• Disruptive behavior disorder increases risk (depression + anx or Oppositional Defiant Disorder)
• Substance use increases risk
• Contagion – behavior of peers influences risk
• Deny ideation
• Midjudge lethality
• Stressor within last 24 hrs

Question 9

SSRI Use in Adolescents

Answer 9

Increases risk of ideation, no change in risk of attempts or completion

Denying SSRIs to depressed 15‐24 y/o increases rate of suicide

Question 10

Medications That Reduce Suicide Risk

Answer 10

• Lithium
• Clozapine
• Carefully assess ideation when tapering these medications; and taper very slowly
• Rapid taper of ADMs, meds in bipolar disorder increases risk

Question 11

Suicide Assessment

Answer 11

ASKING WILL NOT INCREASE RISK

• Gently engage patient
• Calmly reassure
• Gradually increase focus on content
• Ask questions that encourage pts to answer honestly
• Find out “the tipping point”
• Obtain collateral information whenever possible.
• Ask family members if the patient has been talking about death or suicide – 60% completers have told spouse, 50% have told family.
• Remember that risks multiply each other

Question 12

What to ask

Answer 12

• How do you see the future?
• Have you felt that life is not worth living?
• Have you had thoughts of wanting to end your life?
• What plans have you made to end your life?
• What means do you have available?
• Are there weapons at home?
• Do you believe those means will kill you? (perceived lethality)
• Have you begun preparations to die?

Question 13

Perceived Lethality

Answer 13

More important than the actual lethality of a method

If patient believes what he did/will do will cause his death it connotes far greater risk for future suicide

Question 14

Beware of certain beliefs

Answer 14

• Death as a solution
• Better off without me
• Deserve to die
• Decrease pain by dying
• If I try to kill myself I’ll know if he/she loves me
• They will be sorry

Question 15

Suicide Risk

Treatment Approach

Answer 15

Level of care depends on risk:

• Severe
  
  • Hospitalize
  • 24 hr monitoring
• Moderate
  
  • Refer to psychiatrist for urgent evaluation
  • Regular assessment re: need for hospitalization and severity of ideation
  • increased contact
  • family support
  • focus on immediate attainable goals,
  • 24 hr crisis access
  • pharmacotherapy
  • partial/day hospital
  • Must have collateral information and good supports if specialty care not immediately available or hospitalization is advisable
• Mild
  
  • Refer to psychiatrist
  • Regular and periodic risk assessment

Question 16

Determining Level of Care

Answer 16

• Acute risk
  
  • Severe anxiety
  • Severe anhedonia
  • Recent alcohol
  • Insomnia
  • Moderate to severe depression
  • Current mania or psychosis
  • Suicide plan or intent
• Moderate risk
  
  • Moderate anxiety
  • h/o past attempts
  • Dual diagnosis
  • Mild depression
  • Family history
  • Suicidal ideation
  • Hypomania

Question 17

Provider

Plan of Action

Answer 17

Have an action plan in place before patient is identified:

• Who are your referral sources (particularly for pts without insurance)?
• What are your state civil commitment laws?
• Ask about availability of weapons and implement plan for their removal – means restriction is a critical part of prevention
• Where is closest ER?
• Where can patient wait?
• Is the room safe?
• How will you keep patient safely in the office awaiting transport?
• Who will sit w/ the patient?

Question 18

Patient

Safety Plan

Answer 18

• In an emergency you must have a plan (do x, y, z if this happens).
  
  • Our roadmap for your plan is the chain of events that sets suicide thoughts in motion and the ways you can combat them.
• Warning sign ⇒ Follow the Steps of the Plan in Order
  
  • Get professional help at once if you are in danger of acting on impulses.
• Make the Plan Effective and Specific
  
  • At each step
  • Provide a rationale
  • Ask patient for ideas and brainstorm further solutions
  • Elicit likelihood of follow‐through
  • Identify obstacles and brainstorm solutions
• Make the Environment Safer
• Finding Reasons to Live
  
  • Ask pts for reasons to live
  • Add details that amplify meaning and emotional connection to these reasons.
  • If individual has difficulty identifying reasons to live, ask questions that break through hopelessness and pessimism.
• Build a Hope Box
  
  • Pictures
  • Letters
  • Poetry
  • Prayer Cards
  • Coping Cards
  • Meaningful mementos or tokens
  • Container can be anything as long as it is easily accessible (e.g., shoebox, folder, phone app)

Question 19

Suicide Contracts

Answer 19

• Not effective
• Only work when the patient refuses to make one
• Do not protect you in court
• Make a Safety Plan Instead
• Assure that the patient is committed to making changes that make life worth living
• Assess risks accurately
• Assess the patient’s ability to keep treatment agreements prior to determining level of care