Managing suicide risk: changeability, confidence, corroboration and common sense

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Managing suicide risk changeability,
confidence, corroboration and common sense

• Dr Nick OConnor
• August 2008

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Australasian Psychiatry Vol.12 No. 4. December
2004 p352- 360

• Changeability, confidence,
• common sense and corroboration
• comprehensive suicide risk
• Assessment
• Nick OConnor, Monica Warby, Beverley Raphael and
• Tony Vassallo

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All health professionals

• Engagement Detection
• First line Suicide Risk Assessment
• Immediate management

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Engagement

• Engagement is crucial to detection, assessment
  and management of suicide risk
• Clinician takes responsibility for maximising
  engagement
• Level of engagement is assessed
• Limits of confidentiality are discussed

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Detection

• Engagement is first base in detection
• Detection is about identifying risk
• Most people seek help prior to acting on suicidal
  impulses
• It is important and safe to ask
• 1. Pirkis J, Burgess P. Suicide and recency of
  health care contacts. A systematic
• review.British Journal of Psychiatry 1998173
  462474.
• 2. Lawrence D, DArcy C, Holman J, Jablensky AV,
  Fuller SA, Stoney AJ. Increasing
• rates of suicide in Western Australian
  psychiatric patients a record linkage study.
• Acta Psychiatrica Scandinavica 2001 104 443451.

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First line assessment of suicide risk

• Manner of presentation/referral
• History of presenting problem
• Brief psychiatric assessment
• Collateral information
• Assessment of suicide risk

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Immediate management

• Safety of person, clinician, others
• Appropriate observation, supervision
• Medical condition requiring management
• Referral for specialist assessment/ consultation

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Mental health professionals

• Psychiatric assessment
• Comprehensive suicide risk assessment
• Common sense
• At risk mental states
• Changeability
• Corroboration
• Confidence (managing uncertainty)
• Assignment of risk level
• Management of risk

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Psychiatric assessment

• Most people who suicide are suffering from a
  psychiatric disorder
• Demographic risk factors can guide but not
  replace risk assessment there is no effective
  rating scale
• The clinical assessment and clinicians themselves
  are the best assessment instruments
• 3. Conwell Y, Duberstien PR, Cox C, Herrmann JH,
  Forbes NT, Caine ED. Relationships
• of age and axis I diagnosis in victims of
  completed suicide a psychological autopsy
• study. American Journal of Psychiatry 1996 153
  20022008.
• 4. Barroclough B, Bunch J, Nelson Bet al. A
  hundred cases of suicide clinical aspects.
  British Journal of Psychiatry 1975 125 355373.
• Pokorny 1983, Goldstein 1992

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Comprehensive suicide risk assessment

• Common sense
• Corroboration
• At risk mental states
• Changeability
• Confidence (managing uncertainty)

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Common sense

• Careful history taking consistency, plausibility
• Forensic chronological history of a suicide
  attempt (Sheas CASE approach)
• Corroborative history
• Shea S.C. 2002 The Practical Art of Suicide
  Assessment. John Wiley Sons

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At risk mental states

• Hopelessness
• Despair
• Guilt
• Shame
• Anger
• Agitation
• Psychosis

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Changeability

• Suicide risk is by nature dynamic
• Recognising highly changeable risk assists in
  determining management and review
• Many factors may lead to high changeability
• Impulsivity
• Drugs and alcohol
• External contingencies family relationships,
  court case pending

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Confidence

• Reflective practice managing uncertainty
• Issues that may lead to low confidence
• Poor engagement, rapport
• Gaps in history, or implausible accounts of
  events,
• Lack of corroborative sources
• Clinical paradoxical improvement of a suicidal
  person in early phase recovery of depression

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Suicide risk rating
HIGH
Changeability
MEDIUM
Confidence
LOW
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Managing suicide risk

• Aims to get the person through the risk period
• Safety and support
• Treatment of psychiatric disorder
• Avoidance of drugs and alcohol
• Enlist family and social supports
• Reduce stressors
• Contingency planning
• Review assessment

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Implementation

• Education and training
• Assessment proforma (MHOAT)
• Clinical audit
• Application of standard to SERs, Investigations
• Evaluation