Suicide Risk Assessment: Framework and Key Elements Beth

Suicide Risk Assessment: Framework and Key Elements Beth

Suicide Risk Assessment: Framework and Key Elements Beth Brodsky, Ph.D. Conducting Suicide Risk Assessments in Clinical and School Settings NYS Suicide Prevention Conference September 12-13, 2016 Albany, NY Mr. D Mr. D is a 23 year old single man who lives with a roommate and is a graduate

student in computer science. Current presentation: Mr D is on leave from his graduate program because he had been missing class and not handing in assignments. He presents for outpatient psychotherapy because he is depressed, having trouble getting out of bed. He wants to be able to resume his studies. Smoking pot almost daily, occasional use of cocaine. Past psychiatric history: He has a history of 2 suicide attempts with low medical lethality, impulsive overdoses precipitated by interpersonal interactions with teachers and fellow students, and feelings of failure regarding his school performance. He reports a history of sexual abuse in childhood, history of impulsive/aggressive behaviors, history of non-suicidal self-injury (cutting). Last suicide attempt was 3 months ago when he was placed on medical leave, an overdose of 20+ pills mix of antidepressants and benzodiazepines. Fell asleep, never sought or received medical treatment. No current suicidal ideation. Since the attempt, he has engaged in three episodes of non suicidal self injury, cuts himself on his chest with an exacto knife, for the purposes of relieving

feelings of anger, with no intent to die. Suicide Risk Assessment in Context: Points of Intervention to Prevent Suicide Population Prevention Health Measures Public Screening Individualized Risk Assessment Triage Decisions Brief Intervention Strategies: Safety Planning/ Treatment Engagement Strategies/ Structured Follow-up and Monitoring Treatment Strategies:

How do we determine Mr. Ds suicide risk? Recent suicide attempt History of remote suicide attempt Current NSSI Mr. D denies any current suicidal ideation. Does that mean he is not at risk for suicidal behavior in the near future? What else do we need to know to make the best determination of his risk level and how to intervene/monitor? Framework for Risk Assessment

To provide a way of prioritizing and weighing risk and protective factors, rather than just a laundry list of risk factors Risk factors other than suicidal ideation and history of behaviors To guide treatment recommendations and help determine the most appropriate level of care or follow-up action to be taken To provide a framework for documenting a suicide risk formulation based on all risk and protective factors using clinical judgment Features of a Comprehensive Suicide Risk Assessment Never based on any one risk factor (or set of risk factors)

All suicide risk and protective factors are assessed together to provide an overall picture. Identifies factors that are modifiable with intervention. Identifies and distinguishes between Acute/ Proximal risk factors and warning signs from the ongoing, Chronic/ Distal risk factors. Identifies changes in Protective factors

A process that generates specific individual data to guide clinical judgment In an ongoing care situation, risk assessment is not a single event; it must be evaluated over time; risk fluctuates Risk assessment aids, but does not replace, clinician decision-making. Suicide Assessment Indications A positive suicide risk screening result On admission/intake in all clinical settings Prior to change in observation status or treatment setting Abrupt change in clinical presentation

Lack of improvement or gradual worsening with treatment Anticipation or recent experience of loss or stressor Onset of serious physical illness When a suicidal communication is made or implied, e.g. I dont plan on being around in two months. Any precipitant that has increased suicidal risk in the past for the individual Quality of the Suicide Risk Assessment Depends upon: 1. Individuals willingness or ability to accurately disclose information 2. Amount of available time 3. Clinicians style of inquiry 4. Access to the medical record, especially the most recent hospitalization 5. Contact with the individuals family,

friends or clinicians Note: 4-5 above are particularly important if the suicidal individual is not Clinician Style of Inquiry to the Assessment Interviewer style should be direct and not tentativeBalance concern for the individual with not being overly anxious Type of inquiry should be matter- offact but serious If the interviewer is reluctant to ask about suicide risk, the interviewee will be reluctant to reveal information; ask suicide questions in the same way as other questions are asked Key Features of Risk Assessment

Review 7 categories of general risk factors Determine protective factors Weigh risk/protective factors in making a risk assessment Distinguish acute, proximal risk factors from more chronic, distal risk factors, and identify warning signs Use general risk/protective factors to identify an individuals particular risk/protective factors Identify modifiable risk and protective factors Assign a risk level that will inform triage and level and type of intervention Distal Types of Risk Factors Proximal vs. Distal vs. Warning Signs

(chronic, background) risk factors Ongoing general characteristics or factors that are known to be associated with an elevated longer term risk for suicide; they exist in the individuals background Example: Mr. D had a suicide attempt 10 years ago Proximal (acute) risk factors Recent events or exacerbations of ongoing characteristics that can indicate imminent risk Example: Mr. D had a suicide attempt within the last 3 months Warning Signs (most acute risk factors) Individualized behaviors that are directly related to those that precede a spike

in suicide risk in a particular individual, according to individuals history; time frames varies from individual to individual from minutes to days Example: Mr. D is having trouble getting out of bed, which is how he was feeling 3 months ago before he made the attempt 7 Categories of Risk Factors 1. 2. 3. 4. 5. 6. 7. Suicide-specific characteristics Demographic risk factors Psychiatric diagnosis and symptoms

Family and social factors Precipitants Treatment history difficulties Access to means Category 1 Suicide-Specific Characteristics Lifetime Lifetime history of suicidal behavior and recent suicidal ideation Suicidal intent (wish to die) associated with past behaviors and past and current ideation History of non-suicidal self-injury

Past History of Suicide Attempt The most known risk factor for a future suicide attempt is a past suicide attempt Obtaining details about past suicidal behavior can help create an individualized risk profile Identify circumstances and context surrounding one past behavior (preferably the most recent) Precipitant, mood state, recent life change, method,

medical lethality, intent, extent of planning Compare current presentation with the past situation to help determine current risk for this individual General Risk Factor Category 2 Demographic Background Demographic risk factors are distal (background) risks Suicide death demographic risk factors: Middle age 44-65, and over 85-highest age risk groups Adolescents/young adults are also at increased risk Male (4:1 male:female)

Caucasian Suicide attempts demographic risk factors: Female (3:1 female:male) Ages 15-24 General Risk Factor Category 3 Psychiatric Diagnoses Major Depressive Bipolar Disorder Schizophrenia Disorder and Schizoaffective Disorders Anxiety Disorders Substance Abuse/Dependence Disorders Eating Disorders

Post Traumatic Stress Disorder Conduct Disorder Borderline and Antisocial Personality Disorder Psychiatric Symptoms of Concern Current major depressive episode or mixed mood state Command Hallucinations, loss of reality testing Hopelessness, especially chronic hopelessness Acute agitation or severe anxiety Homicidal ideation Aggressive behavior towards others Problem solving deficits Perceived burden on family or others Abrupt change in clinical status

General Risk Factor Category 4 Family and Social Factors: Can be Proximal or Distal Distal factors: Parental history of psychiatric illness Family history of suicidal behavior Childhood sexual and physical abuse Childhood neglect Veteran of wartime military service (depending on how recently) Proximal factors: Recent interpersonal loss or disruption of interpersonal relationships Recent experience of being bullied Few or no social supports 5 Precipitants: Recent Events

Divorce, Activating separation or other interpersonal loss Death of spouse/partner, family member, close friend Chronic physical pain Other acute (or newly diagnosed) serious medical problem, e.g. AIDS, Traumatic Brain Injury, COPD, cancer Legal problems Financial difficulties, unemployment or change in job status Pending incarceration or homelessness Being bullied (particularly among adolescents) General Risk Factor Category 6 Psychiatric and Substance Use Treatment History Previous psychiatric

Hopelessness about diagnoses or dissatisfaction with treatment Non-adherence to treatment Not receiving treatment for current illness Refusal or inability to agree to use a safety plan; unable to feel confident in the ability to stay safe General Risk Factor Category 7 Access To Means Always inquire into access to and availability of any means and

especially those that the individual is considering as part of a suicide plan: Firearms Pills, ingestible poisons Sharps High places such as rooftops, bridges Materials/opportunity for hanging or asphyxiation Weighing the Risk Factors The highest risk factors are those that are most proximal (acute): Current presentation of suicidal ideation or recent suicidal behavior Current mood or psychiatric state Agitation, mania, psychosis, aggression, mixed mood state

Recent high risk precipitants Changes in treatment or situation that are stressful Discharge from inpatient hospitalization Discharge from Emergency Department Impending incarceration or homelessness Loss of social support Job or financial loss Severe medical diagnosis Protective Factors Expression of hope for the future Identification of reasons for living Sense of responsibility to family or others; living with family Children in the home; pregnancy Supportive social network or family

Fear of death or dying due to pain and suffering Belief that suicide is immoral, high spirituality, religious prohibition Positive coping or problem-solving skills Positive current therapeutic relationship Engaged in work or school Protective factors may become operationally not relevant this then adds to risk Assigning a Risk Level for prevention, not prediction Assigning a risk level helps with triage Helps with longer range intervention planning To be used ONLY along with clinical judgment NOT a rigid formula Guidelines for taking into account risk factors to determine risk level are suggestions not mandates

It is not a reliable way of predicting who will go on to die by suicide in the near term (low predictive validity) Take home message: use risk stratification to drive prevention interventions, not prediction Assign Level of RIsk High Risk Acute, imminent, proximal risk factors , protective factors clearly outweighed by risk factors; suicidal intent/ plan/recent suicidal behavior Moderate Risk More distal than proximal risk, protective factors present but not as prominent, no immediate suicidal intent Low Risk No acute, proximal risk factors, strong protective factors, no suicide intent Assessment Informs

Intervention High risk Inpatient psychiatric admission or Intensive outpatient care followed by outpatient treatment Other suicide precautions such as involving friends and family to create a social support safety net for close monitoring as outpatient Safety Plan Intervention Structured Follow-up and Monitoring Moderate Risk Possible inpatient admission Safety Plan Intervention with emergency and crisis plan Structured Follow-up and Monitoring Outpatient treatment

Low Risk Consider outpatient treatment Safety Plan Intervention including an emergency and crisis plan Risk Formulation Risk factors are general population derived characteristics associated with increased suicide risk A clinicians risk formulation weighs population- based risk factors and the individual presentation to ascribe a level of risk

Risk formulation shows clinicians' rationale behind assigning a level of risk and supports the treatment plan Always clearly document your risk formulation Mr. Ds Risk Formulation Mr. D is a 23 year old graduate student on medical leave who lives with a roommate Salient suicide risk and protective factors: Recent suicide attempt 3 months ago - proximal Currently depressed- proximal Currently engaging in NSSI- proximal Current substance abuse - proximal

Roommate is a good friend, mother is source of emotional support- protective Formulating risk level----Moderate risk Depressed with recent suicide attempt Recent NSSI No suicidal ideation and no evidence that he intends to act and no preparatory behavior. Current depression is not as severe as 3 months ago when he made attempt Has interest in outpatient psychotherapy and is willing to engage in safety planning. Recommended treatment plan to manage suicide risk: Safety planning Structured follow-up and monitoring to encourage the use of his safety plan and engagement in ongoing outpatient care Outpatient treatment

Resources http://zerosuicide.actionallianceforsuicideprev Presentation developed by: Suicide Prevention-Training , Implementation & Evaluation @Center for Practice Innovations at Columbia Psychiatry New York Psychiatric Institute Director: Barbara Stanley, Ph.D. [email protected] Associate Director: Beth Brodsky, Ph.D

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