A Practical Approach to Suicide Risk Assessment

1. A Practical Approach to Suicide Risk Assessment Dr. Sinéad O’Brien College Health Service Trinity College Thursday, June 29th 2006

2. Overview • The Problem of Prediction and the Clinical Usefulness of Risk Factors • Identification of Risk Factors for Suicide • Risk Reduction and Intervention Strategies

3. The Problem of Prediction and the Clinical Usefulness of Risk Factors

4. Risk Factors Vs Risk Predictors • Risk Factor: A characteristic of a large sample of people who have committed suicide that appears to be statistically more common than would be expected; • Risk predictor: A characteristic of a specific living person that indicates the likelihood of imminent suicide for that individual.

5. Risk Factors vs Risk Predictors • Hoped that R.Fs if studied collectively in a specific patient, would also serve as reliable risk predictors, alerting the clinician to an immediate danger of suicide; this has not been demonstrated. • Their usefulness lies in the fact that the patient may be at higher risk (not ‘is’at higher risk’). Red flags that alert the clinician to the need to perform a careful suicide assessment in the patient.

6. Categorization of Risk Factors • Static • Dynamic • Short-Term (Acute) • Long-term (Chronic)

7. Examples of Static Risk Factors • Age • Gender • Marital status • Socioeconomic status • Intelligence • Educational level • Family history • Personal history

8. Examples of Dynamic Risk Factors • Depression / Anxiety / Panic attacks • Psychosis • Substance abuse • Insomnia • Impulsivity • Agitation • Physical illness • Difficult life situation • Availability of lethal means

9. Protective Factors • P. F. lower the risk of following through with the idea or planned action; • Like R.F.s they vary with the clinical presentation of individual patients at risk; • An ebb and flow exists between suicide risk and protective factors; • Protective factors can be overcome by the acuteness and severity of mental illness

10. Examples of Protective Factors • Strong family and social support • Pregnancy • Dependent children • Strong religious beliefs against suicide • Cultural sanction against suicide

11. Examples of Short-term (Acute) Risk Factors • Panic attacks • Severe anxiety • Moderate alcohol abuse • Dysphoric mood (mixed states) • Global insomnia

12. Long-term (Chronic) Risk Factors • Family History • Male gender • Living alone • Lack of social support

13. Long-term (Chronic) Risk Factors • Alcohol abuse • Impulsivity • Profound hopelessness • Medical illness • Rejection by boy-friend / girl-friend • Anniversary of important loss • Suicidal ideation • Prior suicide attempts

14. Key Concept The presence of a psychiatric disorder and a previous history of suicide attempts are the best predictors of future suicide attempts and suicide

15. Greatest Risk of Suicide • During the week after hospital admission • The month immediately after discharge • During the early stages of recovery from a mental illness: patient’s energy level usually increases before the depressed mood improves

16. Suicide Ladder • How bad do you feel? • Do you wish you were dead? • Have you had thoughts of ending your life? (How often, when, how long do they last?) • Have you thought about a particular way? • How close have you come to it?

17. Profound Hopelessness Can be reliably assessed by 2 questions: Will to live: none, weak, moderate to strong Will to die: none, weak, strong Individuals are ambivalent; all suicidal patients wish to die; but those without a will to live are the most hopeless and hence at highest risk

18. Intervention Options • Institutional – what the College can do • Clinical

19. Institutional Intervention Options • Raise awareness • Design opportunies for student involvement in entire community • Staff training • Suicide Prevention Programmes – Stress Magement, Problem Solving, Alcohol/Drugs etc • Ready and easy access to services • Re-evaluation of Conventional Counselling Approach; increased access to Action-Orientated Models and Brief Therapy

20. Alcohol Brief intervention for substance use disorders (FRAMES) Feedback: Concern about current health status, substance use behaviour Responsibility: Open acknowledgement that you can’t make them change that only they can Advice: To reduce or abstain from use Menu of Options: Limit drinks to 4 or less/day, spacing drinks, switching to lower alcohol drinks, not drinking to cope, limiting drinking to social venues, keeping track of drinks, trial of abstinence seeming treatment Empathy: Non-confrontational attempt to see the situation from the patients perspective while still maintaining objectivity Self-Efficacy: Encouraging belief they can change

21. Clinical Interventions • In-patient / Out-patient treatment; • If Out-patient: • Attend to patient safety; • Determine a setting for treatment and supervision; evaluate available support; • Work to establish a cooperative and collaborative physician-patient relationship; • Prescribe Somatic Treatment / psychotherapy • See daily; list emergency contact phone numbers etc.

22. Key Concept Assessment of suicide risk and prevention of suicide are daunting tasks because of the multidimensional nature of ideation and behaviour Despite clinicians’ best efforts at suicide assessment and treatment, suicides can and do occur in clinical practice.