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Suicide Risk: Comprehensive Assessment and Clinical Management

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Title: Suicide Risk: Comprehensive Assessment and Clinical Management


1
Suicide Risk Comprehensive Assessment and
Clinical Management
  • David A. Brent, M.D.
  • Western Psychiatric Institute and Clinic
  • March 28, 2006

2
Objectives
  • 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

3
Descriptive Epidemiology Adolescents
  • 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

4
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
5
Hazard Functions of First Onset of Suicide
Ideation, Plan, and Attempt (N5877)
Kessler et al., 1999
6
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7
Suicide Rates by Age, 1982-2002
Data are from Center for Disease Control and
Prevention
8
2002 Suicide Rates by Race, Gender Age
Data from the Center for Disease Control and
Prevention
9
Assessment of Suicidal Patients
  • Characteristics of suicidality
  • Current and lifetime psychopathology
  • Psychological characteristics
  • Family and environmental factors
  • Availability of lethal agents

10
Characteristics of Suicidality
  • Intent / current ideation
  • Lethality
  • Precipitant
  • Motivation
  • Environmental response

11
Suicidal Intent
  • 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

12
Assessment of Suicidal Ideation
  • 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?

13
Current Suicidal Ideation / 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

14
Progression of Suicidality
  • Ideation to plan 34
  • Ideation to attempt 26 (90 in 1 yr)
  • Plan to attempt 72 (60 in 1 yr)

Kessler et al., 1999
15
Lethality
  • 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

16
Non-Suicidal Self-Harm
  • Self-cutting, repetitive and stereotypical
  • To relieve distress/anger, pain, loneliness
    rather than to die
  • Often co-occurs with suicidal behavior

17
Precipitants
  • 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

18
Motivation
  • 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

19
Psychopathology
  • 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

20
Age and Suicide
  • 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

21
Prediction of Suicide Attempt in Community
Samples
  • Demographic Age 15-24, female,
  • 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

22
Psychological Characteristics
  • 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)

23
Family and Social Factors
  • Parental history of psychiatric illness and
    suicidal behavior
  • Abuse and neglect
  • Discord
  • Disruption of interpersonal relationships
  • Grief
  • Disconnection and drifting

24
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25
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26
Abuse and Neglect
  • 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

27
Family and Social Protective Factors in
Adolescents
  • Parent-child connection
  • High parental expectations
  • Parental supervision and availability
  • School connection
  • Religious affiliation
  • Non-deviant peer group

28
Protective Factors 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

29
Availability of Lethal Agents
  • Case control and quasi-experimental study and
    guns
  • Detoxification of domestic gas
  • Blister packs for acetaminophen
  • SSRIs vs. TCAs

30
Guns in the Home Suicide (OR)
95 CI excludes 1.0
31
Guns in the Home Suicide (OR) Age
95 CI excludes 1.0 Kellermann et al., 1992
32
Rates of Suicide by Firearm During the Six Years
After Purchase Among Persons Who Purchased
Handguns in California 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, 3411583-1589
33
Acetominophen (Paracetomol) 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

34
Toxicity of Antidepressants DAWN
Kapur et al., 1992
35
End of Part I
36
Mnemonic for Assessing Suicide Risk
  • AID ILL SAD DADS

Distal
Proximal
37
Proximal Risk Factors
  • 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

38
Distal Risk Factors
  • 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

39
Suicide Among Inpatients
  • 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

40
Suicide in Psychiatric Inpatients
  • 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

41
Suicide within 3 Months of Discharge
  • 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

42
Suicide within 12 Months of Mental Health Service
Contact
  • 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

43
Risk for Suicide in Mood Disorders (Bostwick,
2000)
  • 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
44
Proximal Risk Factors for Suicide in Depression
  • 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
45
Distal Risk Factors for Suicide in Depression
  • Suicide history - Personal and family
  • Aggression - Impulsive aggression
  • Difficult course Hopelessness
  • Difficult patient - BPD
  • Abuse and trauma
  • Disconnection
  • Substance abuse

46
Proximal Risk Factors for Suicide in Bipolar
Disorder
  • Agitation - Anxiety
  • Ideation - Ideation and recent attempt
  • Depression - More prominent
  • Instability - Mixed state, rapid cycling,
    substance abuse
  • Loss
  • Lethal agents
  • Hawton et.al., 2005a

47
Distal Risk Factors for Suicide in Bipolar
Disorder
  • 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

48
Proximal Risk Factors for Suicide in
Schizophrenia
  • 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
49
Distal Risk Factors for Suicide in Schizophrenia
  • Suicide history - Personal and family
  • Aggression and impulsivity
  • Difficult course
  • Difficult patient - Non-adherent
  • Abuse and trauma
  • Disconnection
  • Substance abuse

Hawton et al., 2005b
50
Proximal Risk Factors for Suicide in Alcoholics
  • 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

51
Distal Risk Factors for Suicide in Alcoholics
  • 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

52
Proximal Risk Factors for Suicide in Eating
Disorders
  • Agitation Obsessive concern about weight
  • Ideation
  • Depression and hopelessness
  • Instability - Drug and alcohol abuse, mood
    lability
  • Loss
  • Lethal agent

53
Distal Risk Factors for Suicide in Eating
Disorder Patients
  • 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

54
Proximal Risk Factors for Geriatric Suicide
  • Agitation - Insomnia, anxiety, traumatic grief
  • Ideation
  • Depression, decline and hopelessness
  • Instability
  • Loss of relationship health, function (in self
    or spouse)
  • Lethal agent

55
Distal Risk Factors for Geriatric Suicide
  • Suicidality - Personal and family history
  • Aggression - Not so prominent
  • Difficult course
  • Difficult patient
  • Abuse and trauma
  • Disconnection from supports
  • Substance abuse

56
Why Target Depression?
  • 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

57
Treatment of Depression Reduces 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

58
Gotland Study Suicide Rates (per 100,000)
Intervention
p 59
Treatment of Depression May NotReduce 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)

60
Khan et al., 2000 FDA Database (n19,639)
61
Storosum et al., 2001 Dutch Studies, 1983-1997
Short Term
Long Term
Suicide Rate
Suicide Rate 0
Placebo
Placebo
62
Changes in Mood and Suicidality NotAlways
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

63
End of Part II
64
SSRIs and Suicidality A Summary of the FDA
Findings
  • 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

65
Pittsburgh Meta-Analysis Efficacy and
Suicidality in Pediatric Clinical Trials for MDD,
OCD and ANX
Response
SuicidalityIndicatio
n 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
66
Suicidality and Antidepressants
  • 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
67
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
68
Treatment Studies of Adult Suicide Attempters
Hawton et al., 1998
69
Dialectical Behavior Therapy (DBT)
  • 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

70
CBT for Prevention of Recurrent Attempts
  • Chain analysis of attempt
  • Focus on cognitions leading to attempt
  • Safety plan
  • Case management
  • Two-fold reduction in re-attempt
  • Brown et al., 2005

71
Survival Curves of Time to Repeat Suicide Attempt
Brown, G. K. et al. JAMA 2005294563-570.
72
Treatment Studies with 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.

73
Effects of Long-Term Contact 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
74
Aftercare Postcards from the Edge
  • 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)
  • RR0.55
  • Reduction in bed-days110

Carter et al., 2005
75
Carter et al., 2005
76
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

77
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
78
Lithium and Odds of Suicidal Behavior
Baldessarini, 2003 Coppen, 2000
Goodwin, 2003
79
Direct Targeting of Suicidal Behavior Clozapine
  • 980 schizophrenic or schizoaffective patients
  • Randomized to clozapine or olanzapine
  • Suicide attempt rate lower in those treated with
    clozapine (34 vs. 55, p0.03)

Meltzer et al., 2003
80
Montgomery et al., 1994 Prevention of
Recurrent Suicide Attempts in Patients with
Recurrent Brief Depression
81
Verkes et al. (1998) Paroxetine for Recurrent
Attempt


p 82
TASA (Treatment of Adolescent Suicide Attempters)
CBT
  • 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

83
Chain Analysis of Suicide Attempt
  • Precipitant
  • Motivation
  • Negative affect
  • Hopelessness
  • Emotion regulation
  • Environmental response

84
Management of External Factors in Treatment of
Attempters
Family Discord
Availability of Lethal Agents
School Problems
Attempt
Interpersonal Difficulties
Social Skills Training
Restrict Access to Means
Case Management Adjust Expectation
Family Therapy , Education Treatment of Parents
85
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
86
In setting treatment priorities, ask
(collaboratively)
  • 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?

87
Relapse Prevention Session
  • Imagine situation that led to attempt
  • Role play how would cope now
  • Identify skills and resources necessary to stay
    well

88
Treatment Guidelines
  • 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

89
Safety Plan
  • 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

90
(No Transcript)
91
Secure Lethal Agents
  • Find out motivation for gun ownership
  • Find out who owns the gun
  • Negotiate most secure situation possible
  • Parental regulation of medication

92
Hopelessness
  • 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

93
Education
  • Educate parents and families about depression as
    a chronic and recurrent illness
  • Depression is nobodys 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

94
Recognize Intercorrelation of Health Risk
Behaviors
  • Unprotected sex
  • Alcohol, drug, tobacco use
  • Weapon-carrying
  • Binge eating and obesity
  • Bullying/being bullied

95
Increase Protective Factors
  • Improve family-patient connection, supervision,
    expectations
  • Improve school connection (when relevant)
  • Choice of friends and romantic attachments /
    marriage
  • Connection to social groups and institutions

96
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

97
Summary
  • 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
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