Gatekeepers of Hope: Suicide Prevention in Pharmacy

1. How to save a Life:Suicide Prevention in Pharmacy Presented by: Carmen Loucks, BScPhm Candidate

2. Why You Should Care • http://www.youtube.com/watch?v=2199PPD8fRw

3. Why I Chose This Topic

4. What would you do…? • Conducting a MedsCheck with Mr. ST

5. Outline • Why pharmacist should play a role • Assess the risk of a suicidal patient • Intervene appropriately with a suicidal patient • Identify available resources

6. Why pharmacists should play a role

7. Why Pharmacists? • Accessible, available, knowledgeable • “Gatekeepers” • Trusted by patients • Frequent monitoring • Nonadherence to antidepressants • Method of choice = drugs

8. Assess the risk of a suicidal patient

9. True or False • The majority of people who commit suicide have a mental disorder.. • TRUE About 90% of suicidal patients have a diagnosable mental disorder.

10. Risk Factors • Depression • Previous suicide attempt • Alcoholism • Schizophrenia • Painful and chronic conditions • Epilepsy • Spinal or head injuries and stroke • Cancer • HIV/AIDS • Other (ie. diabetes, MS) • Difficulty walking, seeing and hearing

11. Who is at higher risk? Patient A (Male) or Patient B (Female)

12. Who is at higher risk? Patient A (Elderly) or Patient B (Young)

13. Who is at higher risk? Patient A (Married) or Patient B (Single)

14. What to Look For Behavioural Clues:

15. What to Look For Verbal Clues: “I want to kill myself” “I want to die” “I’ll never get out of it” “They’d be better off without me” “I have made my will”

16. Protective Factors • Children at home • Pregnancy • Religious faith • Employment • Social support system

17. Intervene appropriately with suicidal patients

18. True or False • People who attempt suicide do not want to talk about it. • FALSE The best way to find out if your patient has suicidal thoughts is to ask them!

19. Initial Contact • Step #1 – Find a private place • Step #2 – Allocate the necessary time • Step #3 – Listen!!!

20. What to Ask To determine their current mental state: • “Do you feel sad?” • “Have you ever felt that life was not worth living?” • “Did you ever wish you could go to sleep and just not wake up?” • “Have things ever reached the point that you’ve thought of harming yourself?”

21. What to Ask To determine their plan: • “How likely do you think it is that you will act on them in the future?” • “Have you made a specific plan to harm or kill yourself?” (If so, what does the plan include?) • “Is the means readily available to you?” • “When are you planning to do it?”

22. What to Ask… To determine what their support system is: • “What things would lead you to feel more (or less) hopeful about the future?” • “What things in your life make you want to go on living?”

23. Risk Level

24. Suicide Risk Assessment Scales • No evidence to support using only summary scores to determine acute risk • Predictive value is low BUT the actual content covered by the questions is important • Useful for pharmacists: • SAD PERSONS • TASR (Tool for Assessment of Suicide Risk)

25. Back to Mr. ST • 46-year-old male • Married 23 years • 3 kids at home • Major depressive disorder, Hypertension • No previous suicide attempts • No suicidal plans • Celexa 20mg daily, Apo-Hydro 25mg daily, Altace 10mg daily • Lost his job • Struggling financially • “I don’t know what to do, I don’t think I’ll ever get out of it”

26. Risk Factors • Male • Major depressive disorder • Job loss • Verbal clues Protective Factors • Married • Kids at home • No previous suicide attempts

27. Mr. ST’s Risk

28. How to Manage Low Risk Patient • Offer emotional support • Encourage the person to talk openly in order to resolve suicidal feelings • Cast doubt • Refer the person to a mental health professional or a doctor • Meet at regular intervals

29. Mr. ST Returns • 1 year later • Divorced, not living with his children • Celexa increased dose • Still unemployed • Drinks 4-5 drinks/day • Came to the pharmacy to get his medications, asking you to dispense a larger quantity • After probing, admits he will use the drugs to kill himself • Timeframe <48h • “The world is better off without me If you don’t give the meds to me, I have rope at my house..”

30. Mr. ST’s Risk

31. How to Manage a High Risk Patient • Stay with the person • Gently talk to the person and remove the means of suicide (ie. pills, knife, rope etc.) • Make a suicide prevention or “no-harm” contract • Contact a mental health professional or doctor immediately • Arrange for ambulance and hospitalization • Inform the family and enlist support

32. Identify available resources

33. Crisis Lines • Distress Centre: Distress line, 24/7 Crisis Line Canadian Mental Health Association/Waterloo Region Branch • Ontario Association of Distress Centreswww.dcontario.org • Ontario Suicide Prevention Network www.ontariosuicidepreventionnetwork.ca

34. Useful Resources INTERNATIONAL • World Health Organization (WHO) http://www.who.int/mental_health/prevention/suicide/suicidepreve nt/en/index.html Guidelines for Primary Health Care Workers 2009 NATIONAL • Canadian Association for Suicide Prevention (CASP) www.suicideprevention.ca Guidelines September 2009 • Centre for Suicide Prevention (Alberta)http://suicideinfo.ca/Library/Resources.aspx • Canadian Patient Safety Institute (CPSI) and Ontario Hospital Association http://www.patientsafetyinstitute.ca/English/toolsResources/SuicideRisk/Documents/Suicide%20Risk%20Assessment%20Guide.pdf Suicide Risk Assessment Guide 2011 LOCAL Waterloo Region Suicide Prevention Strategy 2006-2011

35. True or False • Doctors, pharmacists and veterinarians have higher than average suicide rates. TRUE

36. Professionals Health Program • Offer advice, help, and support to physicians, pharmacists and veterinarians and members of their families who may have substance abuse disorders and/or psychiatric disorders • OPA Website  Membership  Support

37. Please Visit My Website Ever wondered… • What you would do if you received a prescription for a lethal dose of secobarbital • About medications used to treat suicide • What a suicide cluster is and what can be done about it http://www.howtosaveapatientlife.weebly.com

38. Summary • Pharmacists frequently come in contact with the public and are ideally positioned to monitor for depression and nonadherence to antidepressants • Important to be able to identify individuals at risk of suicide • Use probing questions to determine whether the individual is low, moderate or high risk • Remember that most patients contemplating suicide WANT to talk about it!!!

39. References • Vincent, P. (2013, January 10). Suicide Prevention in Pharmacy. Powerpoint lecture presented at Professional Development Week in Montreal. • World Health Organization (2000). Prevention Suicide: A Resource for Primary Health Care Workers. Geneva, SZ. • Perlman CM, Neufeld E, Martin L, Goy M, & Hirdes JP (2011). Suicide Risk Assessment Inventory: A Resource Guide for Canadian Health care Organizations. Toronto, ON: Ontario Hospital Association and Canadian Patient Safety Institute. • Ontario Association of Distress Centres. www.dcontario.org. • Ontario Suicide Prevention Network. www.ontariosuicidepreventionnetwork.ca • Centre for Suicide Prevention (Alberta)http://suicideinfo.ca/Library/Resources.aspx • http://www.psychpage.com/learning/library/counseling/suicide.html • Lenard, H. (2006). Waterloo Region Suicide Prevention Strategy. Waterloo, ON: Waterloo Region Suicide Prevention Strategy Planning Group. • Professionals Health Program. http://php.oma.org/ • OPA Website. http://www.opatoday.com/index.php/membership/support-services.html