Suicide Risk Assessment Flashcards
How many suicides occur per year in the US?
What % are inpt?
35,000 / year (4th leading cause of death in US)
5-6% inpt
What is the strongest predictor of suicide?
Psychiatric illness
2/3 have seen MD w/in month of their death
How many ppl will have suicidal ideation ever?
1/3
What is the difference b/w suicide prediction and suicide risk assessment?
- Prediction: fortelling at some future time
- Risk assessment: clinical judgment of risk in very near future
What are the 5 tasks in suicide risk assessment?
- ID risk factors
- ID protective factors
- Specific suicide inquiry
- Risk level determination and intervention
- Documentation
What are the 2 general categories of suicide r/f’s?
Static vs. dynamic/modifiable
What must you consider during a suicide inquiry?
Reliability of the pt (are you and pt in an alliance, or are you an adversary?)
1 in __ inpt suicides lead to lawsuit, 1 in __ outpt suicide leads to lawsuit.
2, 5
When should you do documentation for suicides?
- 1st psych assessment/admission
- Prior to d/c
- Any suicidal ideation/behavior
- Any noteworthy clinical change
What should you specifically document with suicides? (3)
- Risk level + basis for risk level
- Tx plan for reducing risk
- *Firearms (pertinent negative as well)
Which races are at higher risk for suicide?
Which races if the age is > 65?
Which races in teens/early 20s?
- Whites, native americans 2x’s > Hispanics, AAs, Asians
- Age > 65: whites, Hispanics, Asians
- Highest rates, teens/early 20s: native Americans, AAs
How are suicide rates affected by relationship status?
Pregnancy?
Single 2x likely, divorced/separated/widowed 4-5x more likely
- Marriage is protective (but can be r/f if high conflict, violence, etc)
Pregnancy lowers risk, but increases risk for teens, low socioeconomic status.
Does LGTBQ alter suicide risk?
Yes, increases
What occupations are at increased suicide risk?
Physicians, dentists, nurses, artists, social workers, mathematicians, scientists
*What is the #1 r/f for suicide?
Prior attempts
but most ppl who commit attempts will not die by suicide
If someone has 1 suicide attempt, how many times more likely are they to die by suicide?
38x
What psych illness are r/f’s for suicide? (how much do each increase the risk?)
Mood disorders
- Depression (12x)
- Bipolar depression (20x)
- Schizoaffective d/o (^ risk vs schizophrenia)
Substance abuse
- 20-50% of pts who die by suicide are intoxicated
In terms of prediction of suicide, what is a bigger r/f: a certain mood d/o, or #s of combined d/o’s?
Combined d/o’s
Besides increasing suicide risk, what other related factor does drinking increase the risk of?
Using a gun
Do more F or M suffer from depression?
Is M or F suicide risk higher?
2-3x more F than M suffer from depression, but M suicide risk still much higher!
Is M or F suicide risk higher in pts w/BD?
=
Is completed suicide risk higher in M or F? By how much?
M, 4x
How does family hx act as a r/f for suicide?
Increased risk x4
Which types of physical illnesses are bigger r/f’s for suicide? (2)
- Nervous system d/o’s
- Chronic conditions (even higher risk than fatal conditions)
When does a physical illness become a dynamic r/f for suicide?
If recent worsening, esp if that condition is treatable
What types of abuse are r/f’s for suicide?
- Sexual/physical/domestic (domestic is r/f for witnessing kids and abuser)
What is the increased risk of suicide s/p recent purchase of handgun?
30x
- Women more likely to shoot heart, men head
- Hanging is more lethal (85%) than firearms (75%)
How are psychiatric hospitalizations a/w increasing risk of suicide?
Risk higher:
- right after d/c (have pt f/u)
- s/p admission
What are some psychosocial r/f’s for suicide?
- Recent loss of support
- Poor family relations
- Domestic partner violence
- Drop in socioeconomic status
- Unemployment (esp >45 y/o)
- Anything humiliating (eg swindled, financial ruin, scandals)
What are some psychosocial protective factors for suicide?
- Sense of responsibility to family, having kids in home (except postpartum mood/psychotic d/o)
- Religious beliefs
- Life satisfaction
- Positive social support
- Positive therapeutic relationship
- Positive coping skills
- Positive problem solving skills
- Reality testing ability
Describe the suicide age peaks over time in men and women.
- In males, bimodal peaks of suicide in 20-50s, then small bump in 70s
- In females, small bump in 30s-50s, but generally lower overall
(Midline (25-69), suicide rates plateau. Elderly (70+), suicide rates rise again. But rate varies with gender, race, ethnicity)
What is the rate of suicide attempts to completions in adolescence? Elderly?
- Adolescence, 200:1
- Elderly, 4:1
When are murder-suicides more common?
- Young male with sexual jealousy
- Elderly male w/ailing spouse
What is the first approach you should take w/pts contemplating suicide?
Attempt to establish an alliance
- Ideally: have curiosity and concern for pt, also have a collaborative approach
How many more times pts have suicidal ideation vs. make attempts?
How many more times pts make suicide attempts vs. commit suicide?
8x
10-20x
What are some measures that indicate the pt had a high intent to commit suicide?
- Taking measures to avoid discovery
- Using a gun vs knife
- Injured from attempt
- Suicide note
(Ask if they expected to die; get details–timing, setting, prep, etoh, etc)
*What are the components of a Specific Suicide Inquiry?
1) Ideation: intensity, freq, duration, (past 48 hrs or worst ever?)
2) Plans: timing, location, lethality, availability, prep
3) Behaviors: past attempts, aborted attempts, rehearsals
4) Intent: Extent pt expects to carry out plan, believes plan to be lethal vs. self-injurious, ambivalence (reasons to live vs. die), suicide note
5) Lethality (if pt thinks something is more dangerous than it actually is, high intent. If pt thinks its less dangerous than it is, still significant r/f cuz pt can accidentally die.)
What clinical judgment must you make, w/r/t suicide?
Low vs. mod vs. high risk
If someone’s suicide risk is judged low, what are some possible interventions?
(eg modifiable r/f’s, strong protective factors, thoughts of death w/o plans, intent, or behavior)
- Outpt referral
- Symptom reduction
- Provide emergency crisis #
- Address r/f’s
If someone’s suicide risk is judged moderate, what are some possible interventions?
(eg multiple r/f’s, few protective factors, ideation w/plan but no intent, behavior)
- Consider admission depending on r/f’s
- Develop crisis plan
- Provide emergency crisis #
- Address r/f’s
If someone’s suicide risk is judged high, what are some possible interventions?
(eg psych dx w/severe sx, or acute ppt’ing event [protective factors irrelevant], potentially lethal attempt or persistent ideation w/strong intent or suicide rehearsal)
- Usually admit (unless significant change reduces risk)
- Suicide precautions
- Address r/f’s
What are some non-modifiable r/f’s for suicide?
- Demographics
- PMHx
- Fam hx
- Financial/unemployment
What are some modifiable r/f’s for suicide?
- Pt safety
- Psychiatric illness
- Sx
- Psychological problems
- Social problems
Which 2 tx’s have evidence for short-term reduction in suicide?
- ECT
- Clozapine (other antipsychotics do not)
What tx can decrease suicide risk in pts w/BD or MDD?
Lithium (anticonvulsants do not)
What types of medications are often prescribed in suicidality?
Antidepresssants
What is the key element of psychotherapy, w/r/t suicide?
Positive and sustaining therapeutic relationship
- Can treat mild-mod depression w/psychotherapy only
Does pt have to be admitted if they are having thoughts of suicide? Why or why not?
No, psychiatric admission is a r/f for suicide
*What should you do once a suicide occurs?
- Ensure pts records are complete; if you do addendum, show that it happened s/p suicide
- Be there for fam
- Confidentiality remains for med records
- Seek support from colleagues, supervisors
- Consult risk managers about what else to do/not do
Although outdated, what are the 5 axes for psych dx?
1: psych and substance.
2: personality dysfunction and mental retardation.
3: medical problems.
4: stressors.
5: global assessment of functioning
