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

Suicide Risk: Comprehensive Assessment and Clinical Management

David A. Brent, M.D.

Western Psychiatric Institute and Clinic

March 28, 2006

• 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

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

Lifetime ideation 13.5%

Ideation with a plan 3.9%

Attempt 4.6%

*Kessler et al., 1999

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

*Kessler et al., 1999

Data are from Center for Disease Control and Prevention

Data from the Center for Disease Control and Prevention

• Characteristics of suicidality
• Current and lifetime psychopathology
• Psychological characteristics
• Family and environmental factors
• Availability of lethal agents

• Intent / current ideation
• Lethality
• Precipitant
• Motivation
• Environmental response

• “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

• 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?

• 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

Ideation to plan 34%

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

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

*Kessler et al., 1999

• 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

• Self-cutting, repetitive and stereotypical
• To relieve distress/anger, pain, loneliness rather than to die
• Often co-occurs with suicidal behavior

• 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

• 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

• 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

• 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

• 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

• 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)

• Parental history of psychiatric illness and suicidal behavior
• Abuse and neglect
• Discord
• Disruption of interpersonal relationships
• Grief
• Disconnection and “drifting”

• 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

• Parent-child connection
• High parental expectations
• Parental supervision and availability
• School connection
• Religious affiliation
• Non-deviant peer group

• 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

• Case control and quasi-experimental study and guns
• Detoxification of domestic gas
• Blister packs for acetaminophen
• SSRIs vs. TCAs

*95% CI excludes 1.0

*95% CI excludes 1.0

† Kellermann et al., 1992

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

• 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

Kapur et al., 1992

End of Part I

AID ILL SAD DADS

Distal

Proximal

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

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

• 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

• 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

• 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

• 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

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

• 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

• Suicide history - Personal and family
• Aggression - Impulsive aggression
• Difficult course – Hopelessness
• Difficult patient - BPD
• Abuse and trauma
• Disconnection
• Substance abuse

• Agitation - Anxiety
• Ideation - Ideation and recent attempt
• Depression - More prominent
• Instability - Mixed state, rapid cycling, substance abuse
• Loss
• Lethal agents

*Hawton et.al., 2005a

• 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

• 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

• Suicide history - Personal and family
• Aggression and impulsivity
• Difficult course
• Difficult patient - Non-adherent
• Abuse and trauma
• Disconnection
• Substance abuse

*Hawton et al., 2005b

• 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

• 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

• Agitation – Obsessive concern about weight
• Ideation
• Depression and hopelessness
• Instability - Drug and alcohol abuse, mood lability
• Loss
• Lethal agent

• 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

• Agitation - Insomnia, anxiety, traumatic grief
• Ideation
• Depression, decline and hopelessness
• Instability
• Loss of relationship; health, function (in self or spouse)
• Lethal agent

• Suicidality - Personal and family history
• Aggression - Not so prominent
• Difficult course
• Difficult patient
• Abuse and trauma
• Disconnection from supports
• Substance abuse

• 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

• 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

Intervention

*p<0.01

• 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)

Short Term

Long Term

Suicide Rate %

Suicide Rate %0

Placebo

Placebo

• 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

End of Part II

• 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

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

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

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

Hawton et al., 1998

• 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%

• Chain analysis of attempt
• Focus on cognitions leading to attempt
• Safety plan
• Case management
• Two-fold reduction in re-attempt

Brown et al., 2005

Survival Curves of Time to Repeat Suicide Attempt*

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

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.

• 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

• 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

Carter et al., 2005

• 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

Forest Plot Showing Meta-Analysis of Suicides Plus

Deliberate Self-Harm in Randomized Trials Comparing

Lithium with Placebo or Active Comparators

Cipriani et al., 2005

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

• 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

*

*

*p<.05

• 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

• Precipitant
• Motivation
• Negative affect
• Hopelessness
• Emotion regulation
• Environmental response

Management of “External Factors” in Treatment 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

Management of “Internal Factors” inTreatment 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

• 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?

• Imagine situation that led to attempt
• Role play how would cope now
• Identify skills and resources necessary to stay well

• 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

• 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

• Find out motivation for gun ownership
• Find out who owns the gun
• Negotiate most secure situation possible
• Parental regulation of medication

• 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

• 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

• Unprotected sex
• Alcohol, drug, tobacco use
• Weapon-carrying
• Binge eating and obesity
• Bullying/being bullied

• Improve family-patient connection, supervision, expectations
• Improve school connection (when relevant)
• Choice of friends and romantic attachments / marriage
• Connection to social groups and institutions

• Sleep hygiene
• Avoidance of tobacco, alcohol and drugs
• Pleasurable activities
• Self-talk and practice of skills
• Exercise
• Detection of relapse

• 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