Suicide risk comprehensive assessment and clinical management
Download
1 / 97

Suicide Risk: Comprehensive Assessment and Clinical Management - PowerPoint PPT Presentation


  • 798 Views
  • Updated On :

Suicide Risk: Comprehensive Assessment and Clinical Management. David A. Brent, M.D. Western Psychiatric Institute and Clinic March 28, 2006. Objectives. Review descriptive epidemiology of suicidal ideation, attempts, and completion

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Suicide Risk: Comprehensive Assessment and Clinical Management' - onella


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Suicide risk comprehensive assessment and clinical management l.jpg

Suicide Risk: Comprehensive Assessment and Clinical Management

David A. Brent, M.D.

Western Psychiatric Institute and Clinic

March 28, 2006


Objectives l.jpg
Objectives Management

  • Review descriptive epidemiology of suicidal ideation, attempts, and completion

  • Review risk factors for suicidality across the life span and diagnostic groups

  • Use risk factors for purposes of suicide risk assessment

  • Review management and treatment of patients who are suicidal or at high risk for suicide


Descriptive epidemiology adolescents l.jpg
Descriptive Epidemiology: Adolescents Management

Suicidal ideation 20%

Suicide attempts 1.3-3.8% males 1.5-10% females

Risk for recurrent attempts 15-30%/year

Risk for completed suicide 0.5-1.0%/year

Increased risk of suicideamong attempters 10-60-fold increased


Descriptive epidemiology of suicidal ideation and behavior in adults l.jpg
Descriptive Epidemiology of Suicidal Ideation and Behavior in Adults*

Lifetime ideation 13.5%

Ideation with a plan 3.9%

Attempt 4.6%

*Kessler et al., 1999


Slide5 l.jpg

Hazard Functions of First Onset of Suicide in Adults* Ideation, Plan, and Attempt (N=5877)*

*Kessler et al., 1999


Suicide rates by age 1982 2002 l.jpg
Suicide Rates by Age, 1982-2002 in Adults*

Data are from Center for Disease Control and Prevention


2002 suicide rates by race gender age l.jpg
2002 Suicide Rates by Race, Gender & Age in Adults*

Data from the Center for Disease Control and Prevention


Assessment of suicidal patients l.jpg
Assessment of Suicidal Patients in Adults*

  • Characteristics of suicidality

  • Current and lifetime psychopathology

  • Psychological characteristics

  • Family and environmental factors

  • Availability of lethal agents


Characteristics of suicidality l.jpg
Characteristics of Suicidality in Adults*

  • Intent / current ideation

  • Lethality

  • Precipitant

  • Motivation

  • Environmental response


Suicidal intent l.jpg
Suicidal Intent in Adults*

  • “Wish to die”— based on self-report of observable behavior

  • Belief about intent

  • Preparatory behavior

  • Prevention of discovery

  • Communication of intent

  • Higher in completers than attempters

  • Predicts reattempt and completion


Assessment of suicidal ideation l.jpg
Assessment of Suicidal Ideation in Adults*

  • Have you ever thought you would be better off dead?

  • Do you have thoughts of wanting to hurt yourself? (intensity and frequency)

  • Do you have a plan?

  • Do you intend to carry it out?

  • What things keep you from acting on your thoughts (Reasons for Living)?

  • What things would increase the likelihood of trying to hurt yourself?


Current suicidal ideation past behavior l.jpg
Current Suicidal Ideation / in Adults*Past Behavior

  • Intensity, now and worst ever

  • Frequency

  • Presence of active plan

  • Wish to carry out plan

  • Past history of attempt particularly within the past 6 months


Progression of suicidality l.jpg
Progression of Suicidality* in Adults*

Ideation to plan 34%

Ideation to attempt 26% (90% in 1 yr)

Plan to attempt 72% (60% in 1 yr)

*Kessler et al., 1999


Lethality l.jpg
Lethality in Adults*

  • Modestly associated with intent

  • But impulsive acts can be very lethal

  • Children can have high intent and low lethality

  • High lethality is associated with higher risk of completion

  • Availability of lethal agents important in younger, impulsive suicides

  • Ratio of attempts to completions drops with age


Non suicidal self harm l.jpg
Non-Suicidal Self-Harm in Adults*

  • Self-cutting, repetitive and stereotypical

  • To relieve distress/anger, pain, loneliness rather than to die

  • Often co-occurs with suicidal behavior


Precipitants l.jpg
Precipitants in Adults*

  • Abuse

  • Family discord

  • Romantic attachment disruption

  • Legal/disciplinary problems

  • Disruption of relationship very high risk for alcoholic suicides

  • Bereavement very important factor in geriatric suicidal behavior

  • Assess likelihood of recurrence


Motivation l.jpg
Motivation in Adults*

  • Wish to die or permanently escape psychological painful situation(1/3 in younger individuals, but increases with age)

  • To influence others

  • Get attention

  • Express hostility

  • Induce guilt


Psychopathology l.jpg
Psychopathology in Adults*

  • Over 80% of attempters and 90% of completers have at least one Axis I disorder

  • Most commonly mood disorder

  • High risk for bipolar disorder, particularly mixed state

  • Substance abuse

  • Cluster B disorders

  • Schizophrenia

  • Comorbidity, chronicity, severity


Age and suicide l.jpg
Age and Suicide in Adults*

  • Suicide attempts and ideation more common in the young

  • Younger suicides more often involve Cluster B, substance abuse, impulsivity, aggression

  • Depression, schizophrenia-- suicide occurs relatively early in course

  • “Pure” depression and planned suicide more common in older adults

  • Alcoholics tend to commit suicide later in the course of the disorder


Prediction of suicide attempt in community samples l.jpg
Prediction of Suicide Attempt in Community Samples* in Adults*

  • Demographic: Age 15-24, female, <12 years old

  • Psychiatric: Mood disorder, psychoses, PTSD, substance abuse, ASP

  • Those with 3+ risk factors are 9.2% of population, but make up 55.1% of all attempters

    *Kessler et al., 1999


Psychological characteristics l.jpg
Psychological Characteristics in Adults*

  • Hopelessness(dropout, poor treatment response, attempt)

  • Impulsivity and aggression (strong predictor of suicidal behavior, especially in presence of a mood disorder, familial component) - More important in suicide earlier in life

  • Social skills deficits(interpersonal problems)

  • Homosexuality, bisexuality(bullying, family rejection)

  • Inflexibility(in older suicides)


Family and social factors l.jpg
Family and Social Factors in Adults*

  • Parental history of psychiatric illness and suicidal behavior

  • Abuse and neglect

  • Discord

  • Disruption of interpersonal relationships

  • Grief

  • Disconnection and “drifting”


Abuse and neglect l.jpg
Abuse and Neglect in Adults*

  • Related to attempt and completed suicide

  • Sexual abuse prominent in early-onset disorders and attempts

  • Parental history of sexual abuse increases risk of attempt in offspring

  • Risk related to severity of abuse

  • Leads to cascade of mental health difficulties: early sexual activity, sexual assault, early pregnancy, marriage, divorce

  • Adversely affects course, adherence to treatment, response to treatment


Family and social protective factors in adolescents l.jpg
Family and Social Protective Factors in Adolescents in Adults*

  • Parent-child connection

  • High parental expectations

  • Parental supervision and availability

  • School connection

  • Religious affiliation

  • Non-deviant peer group


Protective factors in adults l.jpg
Protective Factors in Adults in Adults*

  • Supportive family

  • Live with other people (spouse, child)

  • Children at home

  • Sense of connection and support

  • In older people, “pride in aging”

  • Sense of purpose


Availability of lethal agents l.jpg
Availability of Lethal Agents in Adults*

  • Case control and quasi-experimental study and guns

  • Detoxification of domestic gas

  • Blister packs for acetaminophen

  • SSRIs vs. TCAs


Guns in the home suicide or l.jpg
Guns in the Home & Suicide (OR) in Adults*

*95% CI excludes 1.0


Guns in the home suicide or age l.jpg
Guns in the Home & Suicide (OR): Age in Adults*†

*95% CI excludes 1.0

† Kellermann et al., 1992


Slide32 l.jpg

Rates of Suicide by Firearm During the Six Years After Purchase Among Persons Who Purchased Handguns inCalifornia in 1991

The horizontal line indicates the age- and sex-adjusted average annual rate of suicide by firearm in California in 1991 through 1996 (10.7 per 100,000 persons per year).

Abstracted from Wintemute et al., New England Journal of Medicine, 341:1583-1589


Acetominophen paracetomol and suicide l.jpg
Acetominophen (Paracetomol) Purchase Among Persons Who Purchased Handguns in and Suicide

  • Liver damage associated with > 25 tablets (OR= 4.5)

  • Those with access to bottle vs. blister pack 3 times more likely to take > 25 tablets

  • Only 20% thought a warning would deter them


Toxicity of antidepressants dawn l.jpg
Toxicity of Antidepressants: DAWN Purchase Among Persons Who Purchased Handguns in

Kapur et al., 1992


Slide35 l.jpg

End of Part I Purchase Among Persons Who Purchased Handguns in


Mnemonic for assessing suicide risk l.jpg
Mnemonic for Assessing Purchase Among Persons Who Purchased Handguns in Suicide Risk

AID ILL SAD DADS

Distal

Proximal


Proximal risk factors l.jpg
Proximal Risk Factors Purchase Among Persons Who Purchased Handguns in

Agitation - Anxiety, agitation, EPS, insomnia

Ideation - Active ideation with a plan

Depression - Depression and decline, hopelessness

Instability - Substance use, affective lability, mixed state or rapid cycling, brain injury

Loss - Of relationship, work, health, or function

Lethal agent- Availability of a gun


Distal risk factors l.jpg
Distal Risk Factors Purchase Among Persons Who Purchased Handguns in

Suicidal history - Personal or in family

Aggression and impulsivity

Difficult course - Poor treatment response, comorbid, severe

Difficult patient - Non-adherent

Abuse and trauma history

Disconnection from support, work, relationships

Substance or alcohol abuse


Suicide among inpatients l.jpg
Suicide Among Inpatients* Purchase Among Persons Who Purchased Handguns in

  • Risk 137 / 100,000 admissions

  • Majority on weekend pass

  • In hospital - not on constant observation

  • Admitted for either planning or making an actual attempt

  • Recent bereavement

  • Chronic disorder, psychotic

  • Family history of suicide

    *Powell et al. 2000


Suicide in psychiatric inpatients l.jpg
Suicide in Psychiatric Inpatients* Purchase Among Persons Who Purchased Handguns in

  • 31% of inpatient suicides on unit, usually not on intense observation

  • Judged to be at low risk

  • Staffing, ward design, staff training, observation

  • Often homeless, SPMI, multiple admissions, previous non-adherence and self-harm

    *Meehan et al., 2006


Suicide within 3 months of discharge l.jpg
Suicide within 3 Months of Discharge* Purchase Among Persons Who Purchased Handguns in

  • 32% occur within 2 weeks of discharge

  • Greatest number on first day post-discharge

  • 40% occurred before post-discharge contact with treatment in the community

  • Drugs and alcohol, non-adherence, previous self-harm, personality disorder

  • Prevention through improved treatment adherence and closer supervision (?)

    *Meehan et al., 2006


Suicide within 12 months of mental health service contact l.jpg
Suicide within 12 Months of Mental Health Service Contact* Purchase Among Persons Who Purchased Handguns in

  • Youngest and oldest suicide victims least likely to be engaged in treatment

  • In those under 25 - outreach to those with schizophrenia substance abuse, non-adherence, legal or relationship issues

  • In the elderly, recognition of depression, especially in context of bereavement and decline in physical health; suicide pacts most common in those with ill health in themselves, partner, living alone, low support

    *Hunt et al., 2006


Risk for suicide in mood disorders bostwick 2000 l.jpg
Risk for Suicide in Mood Disorders (Bostwick, 2000) Purchase Among Persons Who Purchased Handguns in

Hospitalized for suicidality 8.6%

Hospitalized 4.0%

Outpatient 2.2%

Non-affectively ill 0.5%

Tends to occur relatively early in the course of illness


Proximal risk factors for suicide in depression l.jpg
Proximal Risk Factors for Suicide in Depression* Purchase Among Persons Who Purchased Handguns in

  • Agitation - Panic attacks, agitation, insomnia, poor concentration

  • Ideation - More specific (intent or planning)

  • Depression – Anhedonia; decline in health in elderly

  • Instability - Alcohol abuse

  • Loss, especially in elderly

  • Lethal agents

*Fawcett et al., 1990


Distal risk factors for suicide in depression l.jpg
Distal Risk Factors for Suicide in Depression Purchase Among Persons Who Purchased Handguns in

  • Suicide history - Personal and family

  • Aggression - Impulsive aggression

  • Difficult course – Hopelessness

  • Difficult patient - BPD

  • Abuse and trauma

  • Disconnection

  • Substance abuse


Proximal risk factors for suicide in bipolar disorder l.jpg
Proximal Risk Factors for Suicide in Bipolar Disorder* Purchase Among Persons Who Purchased Handguns in

  • Agitation - Anxiety

  • Ideation - Ideation and recent attempt

  • Depression - More prominent

  • Instability - Mixed state, rapid cycling, substance abuse

  • Loss

  • Lethal agents

    *Hawton et.al., 2005a


Distal risk factors for suicide in bipolar disorder l.jpg
Distal Risk Factors for Suicide in Bipolar Disorder* Purchase Among Persons Who Purchased Handguns in

  • Suicide history - Personal and family

  • Aggression and impulsivity - ? Role of lithium

  • Difficult course - More time in depressive state

  • Difficult patient – Non-compliant

  • Abuse and trauma

  • Disconnection

  • Substance abuse

    *Hawton et al., 2005a


Proximal risk factors for suicide in schizophrenia l.jpg
Proximal Risk Factors for Suicide in Schizophrenia* Purchase Among Persons Who Purchased Handguns in

  • Agitation, EPS (Extra- pyramidal Symptoms)

  • Ideation

  • Depression and decline

  • Instability - Drug abuse

  • Loss - Recent loss, fear of mental isintegration

  • Lethal agent

*Hawton et al., 2005b


Distal risk factors for suicide in schizophrenia l.jpg
Distal Risk Factors for Suicide in Schizophrenia* Purchase Among Persons Who Purchased Handguns in

  • Suicide history - Personal and family

  • Aggression and impulsivity

  • Difficult course

  • Difficult patient - Non-adherent

  • Abuse and trauma

  • Disconnection

  • Substance abuse

*Hawton et al., 2005b


Proximal risk factors for suicide in alcoholics l.jpg
Proximal Risk Factors for Suicide in Alcoholics* Purchase Among Persons Who Purchased Handguns in

  • Agitation

  • Ideation - Ideation, threat, attempt

  • Depression and hopelessness

  • Instability - Recent heavy drinking, drug abuse

  • Loss - Recent interpersonal loss (within 6 weeks)

  • Lethal agents

    *Murphy, 1992; Conner et al., 2003, 2004


Distal risk factors for suicide in alcoholics l.jpg
Distal Risk Factors for Suicide in Alcoholics* Purchase Among Persons Who Purchased Handguns in

  • Suicide history - Personal and family

  • Aggression - Impulsive aggression

  • Difficult disorder - Early onset, comorbid, chronic course

  • Difficult patient - Non-adherent

  • Abuse and trauma

  • Disconnection

  • Substance abuse (especially polysubstance abuse)

    *Murphy, 1992; Conner et al., 2003, 2004


Proximal risk factors for suicide in eating disorders l.jpg
Proximal Risk Factors for Suicide in Eating Disorders Purchase Among Persons Who Purchased Handguns in

  • Agitation – Obsessive concern about weight

  • Ideation

  • Depression and hopelessness

  • Instability - Drug and alcohol abuse, mood lability

  • Loss

  • Lethal agent


Distal risk factors for suicide in eating disorder patients l.jpg
Distal Risk Factors for Suicide in Eating Disorder Patients Purchase Among Persons Who Purchased Handguns in

  • Suicide - Personal history

  • Aggression and impulsivity - Cluster B personality

  • Difficult course - Poor treatment response, binging / purging, high obsessionality, lower BMI, longer course

  • Difficult patient

  • Abuse and trauma

  • Disconnection

  • Substance abuse


Proximal risk factors for geriatric suicide l.jpg
Proximal Risk Factors for Geriatric Suicide Purchase Among Persons Who Purchased Handguns in

  • Agitation - Insomnia, anxiety, traumatic grief

  • Ideation

  • Depression, decline and hopelessness

  • Instability

  • Loss of relationship; health, function (in self or spouse)

  • Lethal agent


Distal risk factors for geriatric suicide l.jpg
Distal Risk Factors for Geriatric Suicide Purchase Among Persons Who Purchased Handguns in

  • Suicidality - Personal and family history

  • Aggression - Not so prominent

  • Difficult course

  • Difficult patient

  • Abuse and trauma

  • Disconnection from supports

  • Substance abuse


Why target depression l.jpg
Why Target Depression? Purchase Among Persons Who Purchased Handguns in

  • 80% of attempters and 60% of completers are depressed

  • Depression increases the risk for suicidal behavior 10- to 50-fold

  • Quality improvement studies also suggest that improved treatment of depression reduces suicidality risk (Asarnow et al., 2005; Wells et al., 2001; Brown et al., 2001)

  • Pharmacoepidemiological studies show reduction in suicide with SSRI use


Treatment of depression reduces suicidal risk l.jpg
Treatment of Depression Reduces Purchase Among Persons Who Purchased Handguns in Suicidal Risk

  • Gotland study – Improvement in GPs ability to treat depression resulted in decreased suicide rate

  • PROSPECT – Collaborative care for depressed suicidal elders was more effective than TAU for reducing suicidality

  • Pharmaco-epidemiology studies – Increase in SSRI prescription related to decline in suicide, particularly in 15-24 year-olds


Gotland study suicide rates per 100 000 l.jpg
Gotland Study: Suicide Rates Purchase Among Persons Who Purchased Handguns in (per 100,000)

Intervention

*p<0.01


Treatment of depression may not reduce suicidal risk l.jpg
Treatment of Depression May Purchase Among Persons Who Purchased Handguns inNotReduce Suicidal Risk

  • The most suicidal individuals are excluded from clinical trials of depression

  • Suicidality is associated with other factors that also predict treatment non-response of depression (chronicity, severity, comorbidity, personality disorder)


Khan et al 2000 fda database n 19 639 l.jpg
Khan et al., 2000: FDA Database (n=19,639) Purchase Among Persons Who Purchased Handguns in


Storosum et al 2001 dutch studies 1983 1997 l.jpg
Storosum et al., 2001: Dutch Studies, Purchase Among Persons Who Purchased Handguns in1983-1997

Short Term

Long Term

Suicide Rate %

Suicide Rate %0

Placebo

Placebo


Changes in mood and suicidality not always closely related l.jpg
Changes in Mood and Suicidality Not Purchase Among Persons Who Purchased Handguns inAlways Closely Related

  • Suicidal behavior is multifactoral

  • Studies of CBT, IPT, antidepressants differentially decrease depression, but not suicidal ideation, attempts (Brent, 1997; Lerner, 1990; Mufson, 1999; Khan et al., 2000; Storosum et al., 2001)

  • Studies that decrease suicidal ideation / attempts do not affect mood (Linehan, 1991; Harrington, 1998; Wood, 2001)

  • SSRIs may increase suicidal risk


Slide63 l.jpg

End of Part II Purchase Among Persons Who Purchased Handguns in


Ssris and suicidality a summary of the fda findings l.jpg
SSRIs and Suicidality: A Summary of the FDA Findings Purchase Among Persons Who Purchased Handguns in

  • Rate of “suicidality” increased 1.78-fold

  • On average drug vs. placebo, 4% vs. 2%

  • Mostly new or worsened ideation, few attempts, no completions – question clinical significance

  • Early in treatment

  • Most common in trials that also showed increase in hostility

  • No difference in ideation on standard measures

  • More pronounced in non-depressed (e.g., anxious, OCD) subjects


Pittsburgh meta analysis efficacy and suicidality in pediatric clinical trials for mdd ocd and anx l.jpg
Pittsburgh Meta-Analysis: Efficacy and Suicidality in Pediatric Clinical Trials for MDD, OCD and ANX*

Response % SuicidalityIndication N Drug Placebo NNT Drug Placebo NNH

MDD 2,750 59.5 47.9 9 45/1,708 21/1,433 125

OCD 705 51.5 32.2 6 4/362 1/339 200

ANX 1,143 68.9 38.8 3 6/573 1/582 143

*Bridge et al., in preparation


Suicidality and antidepressants l.jpg
Suicidality and Antidepressants Pediatric Clinical Trials for MDD, OCD and ANX*

Drug % Placebo % Pooled Pooled

Risk Difference* Relative Risk*

(95% CI) (95% CI)

MDD 2.6 1.5 0.8% 1.7

(-0.2%-1.8%) (0.97-2.8)

OCD 1.1 0.3 0.5% 1.8

(-0.1%-2.2%) (0.4-8.5)

ANX 0.4 0.2 0.7% 3.1

(-0.0%-1.8%) (0.6-16.8)

*Using random effects models


Slide67 l.jpg

Rates of Suicide Attempts During the 3 Months Before and the 6 Months After Initial Antidepressant Prescriptiona

aBars indicate 95% confidence intervals

Simon et al., 2006


Treatment studies of adult suicide attempters l.jpg
Treatment Studies of Adult Suicide Attempters 6 Months After Initial Antidepressant Prescription

Hawton et al., 1998


Dialectical behavior therapy dbt l.jpg
Dialectical Behavior Therapy (DBT) 6 Months After Initial Antidepressant Prescription

  • Linehan et al., 1991: DBT vs. TAU: 64% vs. 96%

  • 1 year follow-up: DBT vs. TAU: 26% vs. 60% (parasuicide episodes), by 2 years, differences were gone

  • Van der Bosch 2002: lower DSH in BPD with SA

  • Bohus et al., 2004:lower DSH: 38% vs. 69%


Cbt for prevention of recurrent attempts l.jpg
CBT for Prevention of Recurrent Attempts 6 Months After Initial Antidepressant Prescription

  • Chain analysis of attempt

  • Focus on cognitions leading to attempt

  • Safety plan

  • Case management

  • Two-fold reduction in re-attempt

    Brown et al., 2005


Slide71 l.jpg

Survival Curves of Time to Repeat Suicide Attempt* 6 Months After Initial Antidepressant Prescription

*Brown, G. K. et al. JAMA 2005;294:563-570.


Treatment studies with suicidal youth l.jpg
Treatment Studies with 6 Months After Initial Antidepressant Prescription Suicidal Youth

Harrington et al. (1998) – Home-based family intervention no better than TAU for adolescent overdose attempts. In non-depressed group family treatment reduced ideation

Wood et al (2001) – 6-session group treatment >TAU for reducing single (OR=.6) and recurrent attempts (OR=.16), anger, and conduct disorder, but not depression. More of experimental treatment better, more of TAU worse.


Effects of long term contact on suicide l.jpg
Effects of Long-Term Contact 6 Months After Initial Antidepressant Prescription on Suicide*

  • 843 inpatients hospitalized for depression or suicidality and refused ongoing care

  • Randomized to contact or no contact

  • Contact letter with 24 contact, over 5 years

  • Significant in suicide rate difference at 2 years = 1.7-% vs. 3.6%

*Motto & Bostrom, 2001


Aftercare postcards from the edge l.jpg
Aftercare: Postcards from the Edge* 6 Months After Initial Antidepressant Prescription

  • 772 patients who made overdose, ≥ 16 years of age

  • Received postcards (up to 8) and standard treatment vs. standard treatment alone

  • Proportion of repetition in experimental group is lower (15.1% vs. 17%)

  • RR=0.55

  • Reduction in bed-days=110

*Carter et al., 2005


Slide75 l.jpg

Carter et al., 2005 6 Months After Initial Antidepressant Prescription


Pharmacologic targeting of impulsive aggression and or suicidal behavior l.jpg
Pharmacologic Targeting of Impulsive Aggression and/or Suicidal Behavior

  • Lithium – decreases aggression, quasi-experimental findings, decreases suicide rate in adults

  • Neuroleptics – Risperidone decreases aggression in children, RCT clozapine > olanzapine for suicidal schizophrenics

  • SSRIs – decrease in impulsive aggression in one study, did not decrease recurrent suicide attempts in two studies


Slide77 l.jpg

Forest Plot Showing Meta-Analysis of Suicides Plus Suicidal Behavior

Deliberate Self-Harm in Randomized Trials Comparing

Lithium with Placebo or Active Comparators

Cipriani et al., 2005


Lithium and odds of suicidal behavior l.jpg
Lithium and Odds of Suicidal Behavior Suicidal Behavior

*Baldessarini, 2003 †Coppen, 2000 ‡Goodwin, 2003


Direct targeting of suicidal behavior clozapine l.jpg
Direct Targeting of Suicidal Behavior: Clozapine* Suicidal Behavior

  • 980 schizophrenic or schizoaffective patients

  • Randomized to clozapine or olanzapine

  • Suicide attempt rate lower in those treated with clozapine (34% vs. 55%, p=0.03)

*Meltzer et al., 2003


Slide80 l.jpg
Montgomery et al., 1994: Prevention of Suicidal BehaviorRecurrent Suicide Attempts in Patients with Recurrent Brief Depression


Verkes et al 1998 paroxetine for recurrent attempt l.jpg
Verkes et al. (1998) Paroxetine Suicidal Behavior for Recurrent Attempt

*

*

*p<.05


Tasa treatment of adolescent suicide attempters cbt l.jpg
TASA (Treatment of Adolescent Suicide Attempters) CBT Suicidal Behavior

  • Safety plan

  • Case management

  • Chain analysis of attempt

  • Focus on cognitions leading to attempt

  • Two-fold reduction in re-attempt in Brown et al. (2005)

  • Now being tested in multi-site study of adolescent attempters funded by NIMH


Chain analysis of suicide attempt l.jpg
Chain Analysis of Suicide Attempt Suicidal Behavior

  • Precipitant

  • Motivation

  • Negative affect

  • Hopelessness

  • Emotion regulation

  • Environmental response


Slide84 l.jpg

Management of “External Factors” in Suicidal BehaviorTreatment of Attempters

Family

Discord

Availability of Lethal Agents

School Problems

Attempt

Social Skills

Training

Interpersonal Difficulties

Restrict Access to Means

Case Management

Adjust Expectation

Family Therapy , Education

Treatment of Parents


Slide85 l.jpg

Management of “Internal Factors” in Suicidal BehaviorTreatment of Attempters

Negative Affect and other Disorders

Hopelessness

Emotional Lability

Attempt

Problem-solving

Positive Health Habits

Impulsivity

Cognitive Restructuring

Emotion Regulation

Distress, Tolerance, Treatment Disorder


In setting treatment priorities ask collaboratively l.jpg
In setting treatment priorities, ask (collaboratively): Suicidal Behavior

  • What will yield the greatest risk reduction for the least effort?

  • Is it something that can be changed?

  • Does the patient want to / have the capability to change this factor?


Relapse prevention session l.jpg
Relapse Prevention Session Suicidal Behavior

  • Imagine situation that led to attempt

  • Role play how would cope now

  • Identify skills and resources necessary to stay well


Treatment guidelines l.jpg
Treatment Guidelines Suicidal Behavior

  • Establish safety plan

  • Increase likelihood of adherence

  • Determine appropriate level/intensity of care

  • Increase hopefulness about treatment

  • Conduct chain analysis of the attempt

  • Target most relevant individual and environment factors to the suicide attempt

  • Increase protective factors (family connection)

  • Coping plan, hope kit


Safety plan l.jpg
Safety Plan Suicidal Behavior

  • Will try to implement coping plan

  • Promises family and clinician not to engage in suicidal behavior OR

  • Will contact clinician/family/responsible adult if suicidal thoughts reoccur

  • Need 24-hour availability or back-up

  • Review precipitants, develop truce and conduct brief training in emotional regulation

  • Secure lethal agents


Secure lethal agents l.jpg
Secure Lethal Agents Suicidal Behavior

  • Find out motivation for gun ownership

  • Find out who owns the gun

  • Negotiate most secure situation possible

  • Parental regulation of medication


Hopelessness l.jpg
Hopelessness Suicidal Behavior

  • Address hopelessness about treatment first

  • On a scale of 1-10, how hopeful are you that we can help you? What would increase/decrease it?

  • Establish concrete, realistic, achievable goals

  • Reasons for Living

  • Predict “bumps in the road” to prevent undue discouragement


Education l.jpg
Education Suicidal Behavior

  • Educate parents and families about depression as a chronic and recurrent illness

  • Depression is nobody’s fault

  • Help set reasonable expectations regarding chores, school, work

  • Often family members are worried and want information and reassurance from a withdrawn and secretive patient

  • Goal to teach family and patient how to monitor for treatment response, side effects, and long-term course


Recognize intercorrelation of health risk behaviors l.jpg
Recognize Intercorrelation of Suicidal Behavior Health Risk Behaviors

  • Unprotected sex

  • Alcohol, drug, tobacco use

  • Weapon-carrying

  • Binge eating and obesity

  • Bullying/being bullied


Increase protective factors l.jpg
Increase Protective Factors Suicidal Behavior

  • Improve family-patient connection, supervision, expectations

  • Improve school connection (when relevant)

  • Choice of friends and romantic attachments / marriage

  • Connection to social groups and institutions


Education and anticipation relapse and recurrence prevention l.jpg
Education and Anticipation: Relapse and Recurrence Prevention

  • Sleep hygiene

  • Avoidance of tobacco, alcohol and drugs

  • Pleasurable activities

  • Self-talk and practice of skills

  • Exercise

  • Detection of relapse


Summary l.jpg
Summary Prevention

  • Provide a framework for assessing suicidal risk, examining proximal and distal risk factors

  • Discussed the management of the suicidal patient with regard to development and implementation of a safety plan

  • Reviewed empirical data base on interventions to decrease risk of suicidal behavior


ad