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Assessment and Management of Suicide Risk May 24, 2007

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Title: Assessment and Management of Suicide Risk May 24, 2007


1
Assessment and Management of Suicide Risk May
24, 2007
  • Melissa J. Pence, Psy.D.
  • Licensed Clinical Psychologist
  • Hampton Roads Neuropsychology and Behavioral
    Medicine

2
Outline
  • Impact
  • Demographics and epidemiology
  • Etiology
  • Risk assessment
  • Psychological Testing
  • Treatment and prevention
  • Medical-legal concerns

3
A personal account of the impact of suicide
  • " His light, through me, will grow as a beacon
    for others." John C. Gibbs
  • http//www.INeedALighthouse.com/index.html

4
Survivors of Suicide (Schneidman, 1969)

5
Suicide
  • Definition of suicide Suicide is the death
    resulting directly or indirectly from a positive
    or negative act of the victim himself, which he
    knows will produce this result. Emile Durkheim
  • Requires
  • Death/lethal outcome
  • Self-inflicted
  • Intentionally inflicted
  • Awareness or consciousness of outcome

6
Problems in studying suicide
  • Low base rate
  • No test (biological or psychological) or clinical
    marker that predicts suicide
  • Requires clinical judgment
  • Numerous false positives in prediction paradigms
  • High risk suicidal patients excluded from most
    clinical studies

7
Demographics and Epidemiology
  • A MAJOR Public Health Problem!

8
How is this data gathered?
  • Death certificate information reported by each
    state to the National Center for Health
    Statistics
  • Most recent national data available is 2003
  • Numbers are generally understood to be a modest
    underestimation of actual suicide deaths due to
    difficulties in conclusively determining cause of
    death

9
U.S. National Statistics (2003) (CDC)
  • 31,484 deaths by suicide
  • 86 deaths per day
  • 1 every 17 minutes
  • 11th leading cause of death
  • Approximately 787,000 attempts, ratio 251
  • Twice as many people die by suicide than by
    homicide

10
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11
Statistics (2003) (CDC)
12

13
State by State Rate Comparisons
14
Firearms are the Leading Method of Suicide (2003)
15
Data on Means of Suicide (2001)
16
Youth Suicide Rates
  • 3rd leading cause of death in those aged 15-24,
    behind only accidents and homicide.
  • 2nd leading cause of death in college students.
  • 6th leading cause of death in 5-14 year olds.
  • Ratios of attempts to completions estimated to
    range between 1001 to 2001
  • In 2001, firearms were used in 54 of youth
    suicides.

17
Youth Suicide
  • In 1999, 20 of HS students reported seriously
    considering suicide and 8 attempted.
  • Frequent drug and alcohol abuse was found to be
    the most common characteristic in young people
    who attempted suicide (Department of Education)

18
Youth Statistics (2003)
19
Suicide in the Elderly
  • Higher Completion rates (14) over age 65.
  • Medical illness a significant factor in 70 of
    suicides over age 70.
  • Most saw a physician within a few months of their
    death and 1/3 within the previous week.
  • Rate of suicide is 14.8 per 100,000 when compared
    to 10.8 per 100,000 in general population.

20
Male Suicide Rates
  • 8th leading cause of death (2003)
  • 4 times more likely to die by suicide than
    females
  • 60 of suicides involve the use of a firearm
  • Rates are relatively constant between ages 20-64,
    but increase sharply after age 65.

21
Female Suicide Rates
  • Women attempt suicide twice as often as men.
    Some studies suggest the rate is closer to 31.
  • One woman attempts suicide every 78 seconds in
    the U.S.
  • Rates peak between the ages of 45-54 (around time
    of menopause) and again after age 75.

22
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23
Breakdown by Race
  • Caucasians are over 2x more likely to complete
    suicide than African Americans (AA).
  • AA males comprised 84 of suicide deaths in that
    racial group.
  • Firearms predominant method among AAs, regardless
    of gender.
  • American Indian and Alaskan native men have the
    2nd highest rate of suicide after Caucasians.

24
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25
Etiology
26
THE NEUROBIOLOGY OF SUICIDAL BEHAVIOR

27
Familial and Genetic Factors
  • There is a transmission of familial and genetic
    factors that contribute to risk for suicidal
    behavior.
  • Major psychiatric illnesses, such as MDD,
    schizophrenia, and alcoholism have genetic
    component in etiology.

28
Familial and Genetic Factors
  • Several studies have found genetic and familial
    transmission risk is independent of transmission
    of psychiatric illness.
  • First degree relatives of individuals (including
    dizygotic twins) who have completed suicide have
    more than 2x the risk of the general population.
  • For monozygotic twins, risk increases to 11x.
    (Quin, Agenbo, Mortensen, 2002)
  • Recent study could not find genetic effect on
    suicidal ideation. (Farmer et al, 2001)

29
Studies on the Serotonergic System
  • Difficult area to study, numerous methodological
    problems.
  • There is evidence of modest reductions in in
    brain stem/prefrontal cortex serotonin or its
    marker 5-HIAA (metabolite).
  • Lower CSF (cerebral spinal fluid) 5-HIAA levels
    has been reported by most studies in patients
    with a history of suicide attempt and a diagnosis
    of MDD, Schizophrenia, or PD compared to control
    groups of patients with these diagnoses.

30
Serotonergic system, continued
  • Low CSF 5-HIAA level predicts higher rate of past
    and future suicidal acts as well as seriousness
    of suicidal acts over the lifetime.
  • PET scans can map serotonin-induced changes in
    brain activity.
  • Size of abnormality in anterior cingulate and
    prefrontal cortex is proportional to lethality.
  • (Oquendo et al., 2003)

31
Noradrenergic System
  • Reduced noradrenergic functioning is suggested,
    however the evidence is not as strong as in the
    serotonergic system.
  • The conclusion there is a period of
    noradrenergic over-activity (which may be a
    stress response and state dependent) prior to
    suicide which contributes to NE depletion.

32
The Diathesis- Stress Model
  • Proposed by Zubin and Spring (1977)
  • An individual has unique biological,
    psychological and social elements. These elements
    include strengths and vulnerabilities for dealing
    with stress.

33
The Diathesis-Stress Model
34
Becks Cognitive Model (1967)
  • Schema tacit beliefs and memory structures that
    serve to organize the encoding, retrieving, and
    processing of information
  • Latent much of the time
  • May be activated by specific life events
  • Develop from an early age
  • Reinforced and consolidated by life events
  • Schema of depressed individuals thought to be
    rigid, negativistic toward self and others,
    future is bleak, lack control over outcomes.

35
Becks Cognitive Model, Continued
  • Cognitive distortions most frequently associated
    with suicidal ideation
  • Cognitive constriction or tunnel vision
  • Polarized or all or nothing thinking
  • Selective recall of past failure and overlooking
    past success
  • These are believed to play a role in development
    and maintenance of dysfunctional attitudes and
    irrational beliefs.

36
CONDUCTING A SUICIDE RISK ASSESSMENT

37
What is a Suicide Risk Assessment?
  • Refers to the establishment of a clinical
    judgment of risk in the very near future, based
    on the weighing of a very large mass of available
    clinical detail.
  • More than a guess or intuition- it is a
    reasoned, inductive proceess.
  • A necessary exercise in estimating probability
    over short periods.
  • From Jacobs, 2003

38
Who should receive a suicide assessment?
  • ANY patient who meets criteria for DSM-IV mental
    or substance use disorder(s).
  • Should initially occur at the point of entry into
    treatment (i.e. initial visit or intake) and
    periodically as clinically indicated.
  • If the patient meets criteria for a depressive
    disorder and/or manifests any degree of suicide
    lethality, they should be assessed each session.

39
Two Components of Assessment
  • PART 1
  • The elicitation and elaboration of suicidal
    ideation
  • PART 2
  • The identification and qualification of risk
    factors for completed suicide

40
Part 1 Assessing Suicidal Ideation
  • Begin with general questions about self-harm,
    such as asking whether the patient has had
    thoughts of death or suicide. Ask them to
    elaborate in their own words and describe what
    these thoughts are like. Use open ended
    questions.
  • Thoughts should be characterized as active (When
    I am walking, I get the impulse to jump out into
    traffic) or passive (Everyone would be better
    of if I was dead).

41
Assessing Suicidal Ideation, Continued
  • If suicidal thoughts are present, assess how
    often and in what context they occur.
  • Are they fleeting, periodic, or persistent? Are
    the situation specific? Are they increasing or
    decreasing in intensity?

42
Assessing Suicidal Ideation, Continued
  • The patient should be asked if they have a plan,
    or if they have thought of a means in which they
    would use to carry out suicide.
  • Method (availability, lethality)
  • Suicide notes, final acts in preparation for
    death (i.e. will preparation)
  • Has mental rehearsal taken place? Is there a
    plan for a time or place?
  • Have any attempts been made thus far?

43
Assessing Suicidal Ideation, Continued
  • History of similar thoughts, impulses, plans,
    aborted attempts and/or attempts should be
    obtained.
  • Corroborating report from family or providers
    should be obtained (if possible).

44
Assessing Suicidal Ideation, Continued
  • Confidentiality can legally be broken to obtain
    appropriate care if you have evidence to suggest
    the patient is acutely a danger to himself or
    others.
  • Usually necessary information can be obtained by
    simply listening to the family members and it may
    not be necessary to reveal private or
    confidential information to the family.
  • However, in some situations you may be obligated
    to break confidentiality to protect the patient.
    Remain sensitive to family issues and disclose
    necessary information to protect the patient.
  • Helps to discuss this during informed consent at
    the beginning of the process.

45
Assessing Suicidal Ideation, Continued
  • Determine if there are any barriers to suicide.
  • What are the patients reasons for living and
    reasons for dying?
  • How has the patient managed to evade the act of
    suicide thus far?
  • Assess level of current supports (family,
    significant other, friends, employer, therapist,
    etc.)

46
Part 2 Assessing Risk Factors

47
Risk Factor Defined
  • Leading to or being associated with suicide
  • Individuals possessing the risk factor are at
    greater potential for suicidal behavior
  • Some risk factors can be changed or reduced (i.e.
    providing Lithium treatment for Bipolar
    Disorder), others are static (The patients
    father completed suicide)
  • From Suicide Prevention Resource Center,
    www.sprc.org

48
Presence of a mental disorder
  • Present in over 90 of completed suicides.
  • High risk diagnoses are
  • Depression (unipolar and bipolar)
  • Alcohol/substance abuse or dependence
  • Schizophrenia
  • Borderline Personality Disorder

49
Co-morbidity increases risk!
  • Psychological autopsy studies of 229 suicides
  • 44 had 2 or more Axis I diagnoses
  • 31 had Axis I and Axis II diagnoses
  • 50 had Axis I and at least one Axis III
    diagnosis
  • 12 had an Axis I diagnosis with no co-morbidity
  • From Henriksson et al, 1993

50
Recent psychiatric hospitalization
  • Within the last year
  • Acute exacerbation of illness

51
The presence of depression
  • Including hopelessness, guilt, loss
  • Global insomnia
  • Note Hopelessness has been found to be
    co-occurring with depression as well as a
    predictor of suicidal ideation and behavior.

52
Recent or impending loss
  • Loss of job
  • Loss of relationship
  • Loss of loved one, grief
  • Recent move (CDC, 2002)
  • Humiliating events, such as financial ruin due to
    a scandal, being arrested or being fired, can
    lead to impulsive suicide (Hirschfeld and
    Davidson, 1998)

53
Substance or alcohol use
  • Up to 50 of those completing suicide drinking
    alcohol at time of death.
  • Drinking within three hours of the attempt was
    the most important alcohol-related risk factor
    for nearly lethal suicide attempts, more
    important than alcoholism and binge drinking.
    (CDC, 2002)
  • CNS depressants increase risk. (Wines et al, 2004)

54
History
  • History of impulsive or dangerous behavior,
    and/or history of suicide attempts
  • Severe self-mutilation
  • A history of serious suicide attempts may be the
    best single predictor of completed suicide the
    greatest risk occurs within 3 months of the first
    attempt.
  • HOWEVER, the majority of suicides are in
    individuals with no prior attempts.

55
Access to firearms
  • 92 of suicide attempts by firearm are successful
  • Keeping firearms in the home increases the risk
    of suicide for both genders even after other
    factors, such as depression and alcohol use, are
    controlled for.

56
Family history of suicide
  • First degree relatives more than 2x the risk of
    the general population
  • For monozygotic twins, risk 11x.

57
Social isolation or withdrawal
  • Having a strong preference for being alone
    (change from previous behavior)
  • Withdrawing from family, social, or volunteer
    activities
  • Not keeping appointments

58
Concurrent medical disorder
  • Characterized by
  • chronicity,
  • poor prognosis,
  • disfigurement
  • and/or
  • persistent pain.

59
Medical illness, continued
  • Diagnoses most associated with completed suicide
  • Huntingtons Chorea
  • Malignant Neoplasms
  • Multiple Sclerosis
  • Renal disease
  • Peptic Ulcers
  • Spinal Cord injuries
  • Lupus
  • HIV/AIDS
  • Epilepsy (only medical diagnosis documented to
    increase risk in children and adolescents)

60
Severe agitation/anxiety
  • Panic attacks, severe psychic anxiety, and global
    insomnia all significantly associated with
    suicide at one year follow up. (NIMH)
  • Behavioral signs pacing, wringing hands,
    rocking, severe restlessness, etc.
  • Assess for treatment responsive acute risk
    factors, such as askathsia.

61
From Jacobs (2003), Harvard Medical School
62
Depression Unipolar and Bipolar
  • The lifetime risk for suicide in patients with
    mood disorders (major depressive disorder and
    bipolar disorder) is approximately 15-19, and
    the risk is highest in the early stages of the
    illness.

63
Major Depression
  • Factors to consider
  • The concurrent presence of anxiety
  • Substance abuse or dependence
  • Command hallucinations
  • Irritability or anger associated with impulsivity
  • Severe insomnia, especially global insomnia
  • Presence of or access to a gun
  • (Jones et al, 2000)

64
Bipolar Disorder (Goodwin Jamison, 1990)
  • Risks
  • Severe depression with anxiety, agitation
  • Global insomnia
  • Substance abuse
  • Transition periods/early recovery phase
  • Impulsive or violent behavior

65
Bipolar Disorder, continued
  • Assess current mood
  • Typically rates lt 2 during psychotic mania
    (Dilsaver, 1997)
  • 11 directly after remission from mania (Goodwin,
    2002)
  • Approximately 79 during major depressive episode
    (Goodwin, 2002)
  • 11 during mixed state (Goodwin, 2002)

66
Alcohol/Substance Abuse or Dependence
  • The suicide risk among patients suffering from
    alcoholism is similar to that in patients with
    mood disorders, but they tend to commit suicide
    late in the course of alcoholism and are
    frequently depressed at the time of death.
  • Two factors affecting risk (Weiss Hufford,
    1999)
  • Effects of acute intoxication
  • Co-morbid psychopathology such as MDD
  • Risk with recent or anticipated interpersonal loss

67
Schizophrenia (Tsuang, Fleming, Simpson, 1999)
  • Risk Factors for suicide in psychotic patients
  • Young age (lt30)
  • 1 cause of death for young people Dx with
    Schizophrenia
  • Good intellectual functioning
  • Disillusion with treatment
  • Good premorbid functioning
  • Early stage of illness
  • Communication of intent
  • Frequent exacerbations and remissions
  • Painful awareness of the likely degree of chronic
    disability in the future
  • Periods of clinical improvement following relapse
  • Supervention of a depressive episode and
    increased hopelessness

68
Timeline of Risk
69
Borderline Personality Disorder
  • Most likely associated with parasuicidal rather
    than suicidal acts
  • HOWEVER approximately 8.5 of patients eventually
    commit suicide, usually after multiple attempts
    or gestures.
  • Nearly 75 of patients make one attempt in
    lifetime.
  • With alcohol problems19
  • Per Stone (1993) with alcohol major affective
    D/O38
  • Usually qualify for a co-morbid Axis I diagnosis
    at the time of death.
  • Hx of childhood sexual abuse increases the amount
    and lethality of parasuicidal behaviors.

70
Identify Chronic vs. Acute Risk
  • Acute
  • New, acute presentation
  • Presence of significant stressor
  • Emergent response to acute crisis of mood and
    despair
  • Possible co-morbid Axis I disorder
  • Chronic
  • Recurrent and persistent suicidal thoughts that
    provide an ongoing psychological mechanism for
    coping with distress
  • Frequent, usual response to life stresses and
    disappointments
  • Patient may be aware of chronicity

71
Protective Factors
  • Protective factors are believed to enhance
    resilience and serve to counterbalance risk
    factors.
  • An individual's genetic/neurobiological make-up
  • Attitudinal/behavioral characteristics
  • Family/community support
  • Effective and appropriate clinical care for
    mental, physical and substance abuse disorders
  • Pregnancy or children in the home, except for
    post-partum illness

72
Protective Factors, continued
  • Easy access to effective clinical interventions
    and support
  • Restricted access to highly lethal methods of
    suicide
  • Cultural and religious beliefs that discourage
    suicide and support self-preservation instincts
  • Support from ongoing medical/mental health care ,
    positive therapeutic relationship
  • Acquisition of learned skills for problem
    solving, conflict resolution and non-violent
    management of disputes.

73
Prevention and Treatment Strategies
  • Therapeutic Treatment Strategies
  • No Suicide Contracts
  • Pharmcotherapy
  • Hospitalization

74
Prevention/Treatment Strategies
  • ASSESS, ASSESS, ASSESS
  • Assess acute vs. chronic risk
  • 24 hour access to crisis care
  • Strong therapeutic alliance is ESSENTIAL!
  • Work with family and other support systems
  • Use multiple resources, multidisciplinary
    approach

75
Access to Services
  • Crisis services by phone
  • National Hotline
  • 1(800) 273-TALK
  • Emergency Department

76
Prevention/Treatment Strategies
  • Short term coping strategies, behavioral
    treatments
  • Deep breathing
  • Relaxation training
  • Imagery training
  • Grounding
  • Specific, concrete, written safety plan in place
    and frequently renewed and reviewed
  • Access to means removed immediately

77
Dialectical Behavioral Therapy (Linehan, 1993)
  • Developed by Linehan for patients Dx w/ BPD and
    engaging in self-harm behaviors
  • Philosophical orientation focuses on dialectics
  • Move from dichotomous thinking to balance
  • Patients learn to observe and describe, be
    non-judgmental and focus on the present, and
    focus on current activity

78
What is a no-suicide contract?
  • Also known as no-harm contract or safety
    contract.
  • Involves an agreement in which a patient makes a
    verbal or written promise not to harm or kill
    themselves.
  • Commonly used by mental health practitioners,
    including psychiatrists, psychologists, nurses,
    social workers, and therapists.

79
No-Suicide Contracts Usually Contain
  • An explicit statement not to harm or kill
    oneself.
  • A specific duration of time.
  • Contingency plans if contract conditions cannot
    be kept.

80
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81
No Suicide Contracts
  • When the patient doesnt agree.
  • If the patient can not or will not agree to the
    terms of the negotiated contract or if
    non-verbal/historical cues contradict the
    agreement, he/she is usually considered to be at-
    risk.
  • In the presence of a strong therapeutic alliance
    when manipulative behavior is suspected, this
    should be further explored.

82
History of NSCs
  • First documentation in 1973 in study by Drye,
    Goulding, Goulding.
  • Surveyed 31 counselors reporting on 609 patients,
    266 of whom were judged seriously suicidal. 24
    suicides or serious attempts were reported where
    their method for assessment was NOT used and 4
    deaths occurred where their method was used.
  • Method When counselor became aware of SI, asked
    client to repeat, No matter what happens, I will
    not kill myself, accidentally or on purpose, at
    any time (p.172) Then client discussed his/her
    reaction to the statement.
  • Objections or alterations were deemed at risk.

83
No Suicide Contracts Potential Pitfalls
84
Pitfall 1
  • BELIEVING THAT A SIGNED SUICIDE CONTRACT
    ELIMINATES SUICIDE RISK
  • Suicide cannot be absolutely predicted- False
    sense of security.
  • There is no data demonstrating its effectiveness
    or its acceptance in the professional community.
    (Drew, 2001)
  • In one study, 41 percent of psychiatrists had
    patients who committed suicide or made serious
    attempts after entering into a NSC. (Kroll, 2000)

85
Pitfall 2
  • CONTRACT THE LEGAL TERM
  • Clinicians may wish to consider avoiding the word
    contract in their medical documentation.
  • The term may also appear to attempt to free the
    clinician from blame for suicide
    attempts/completions.
  • Appropriate clinical assessment and intervention,
    rather than liability prevention, should be the
    focus of care.
  • Outcomes of legal cases and judgments about
    clinicians care are improved by demonstration of
    comprehensive assessment and treatment.

86
Pitfall 3
  • INFORMED CONSENT???
  • Informed consent is a legal and ethical doctrine
    involving the disclosure of risks, alternatives,
    and facts that allow a patient to make informed
    and unpressured decisions about treatment
    options.
  • The competency of a patient to understand what
    they are signing or to give informed consent to
    such an agreement during a time of crisis is in
    question.

87
Who may or may not be capable of giving informed
consent?
Diagnosis Cited in
Cerebral Impairment Drye et al (1973)
Psychosis Goulding (1979) Egan (1997)
Under the influence of drugs/alcohol Goulding (1979) Egan (1997)
Impulse control deficiencies Davidson et al (1995) Motto (1979)
Severe Depression Egan (1997) Simon (1999)
88
Informed Consent Farrow OBrien (2003)
  • VERY limited data in this area
  • Their study concluded that most patients
    interviewed were not able to participate in
    informed consent for a NSC at the time of
    suicidal crisis.
  • In retrospect, most subjects doubted their
    competence to enter a NSC at the time of crisis.
    My thinking was so confused. I did not
    understand what they were suggesting.
  • Participants reported a strong sense of being
    coerced by clinician.

89
Pitfall 4
  • A safeguard against liability???
  • A NSC may be used as a means to reduce the
    evaluator or therapists anxiety regarding
    litigation.
  • Frequently charted phrases or shorthand such as
    contracted for safety should be avoided without
    appropriate ancillary documentation (suicide risk
    assessment, basis for clinical judgment, plan for
    managing risk.)
  • Providers may believe that securing a NSC
    completes an assessment of suicidality, this is
    short sighted and legally precarious.
  • Range et al, 2000, Stanford et al, 1994, Weiss,
    2001, Miller, 1999, Miller et al, 1998, Lee
    Bartlett, 2005

90
No Suicide Contracts Potential Benefits
91
Benefits
  • A means of evaluating current suicidality
  • One part of a comprehensive suicide risk
    evaluation.
  • Opportunity to discuss suicidal feelings
    directly.
  • Provision of specific behavioral alternatives to
    suicidal acts.
  • Written behavioral plan for patient in a crisis
    situation
  • An adjunct to comprehensive evaluation and
    treatment
  • In the context of a sound and positive
    therapeutic relationship
  • The more concrete, the better! (i.e. written vs.
    oral, specific behavioral strategies tailored to
    the patients needs)

92
Bottom line about NSCs
  • Use NSCs with caution, understanding that they
    are one part of a comprehensive suicide risk
    assessment and treatment plan and have not been
    demonstrated in the literature to reduce suicide
    risk.

93
Pharmcotherapy
  • There are reasons to believe that selective
    serotonin reuptake inhibitors (SSRIs) might
    reduce suicidality.
  • SSRIs remain the preferred psychopharmacological
    treatment for depression.
  • Lithium has a strong, and possibly unique
    protective effect against suicidal acts in
    patients with bipolar disorder. (Baldessarini
    Tondo, 1999)

94
Pharmcotherapy
  • Patients being treated with psychotropic
    medication should be closely observed for
    clinical worsening
  • Agitation, irritability, suicidality, and unusual
    changes in behavior, especially during the
    initial few months of a course of drug therapy,
    or at times of dose changes, either increases or
    decreases.

95
From Jacobs (2003) Harvard Medical School
96
Medical-legal Concerns
97
Litigation
  • Bereaved survivors have a unique grief, often
    feeling hurt, angry, and possibly guilty.
  • May seek compensation for their loss through a
    claim of negligence.
  • Number of lawsuits continues to rise.
  • Hospitals are the primary target, however there
    has been an increase in number of claims against
    outpatient providers.

98
A Shift in the Law (Gutheil, 2000)
  • Before 1940 Suicide was considered an
    independent intervening cause of death
  • After 1940 But for the provider or physicians
    negligence, the patient would not have committed
    suicide (negligence as a proximate cause)

99
Medical-legal Concerns
  • The law recognizes that there are no standards
    for the prediction of suicide and that suicide
    results from a complicated array of factors.
  • The standard of care for patients with
    suicidality is based on the concept of
    "foreseeability"
  • Courts assume that a suicide is preventable if it
    is foreseeable.

100
Medical- Legal Concerns (Lee Bartlett, 2005)
  • Forseeability is defined as A comprehensive and
    reasonable assessment of risk
  • Reasonable care involves Developing a
    comprehensive treatment plan and timely
    implementation based on the assessment of risk,
    or forseeability
  • Failure to assess risk and make sound judgments
    makes the provider a possible target of
    litigation.

101
Risk Management
  • Realistically, a clinician is not always able to
    prevent a suicide in a determined patient.
  • Common themes identified in liability suits
    include
  • lack of an ongoing, documented assessment of
    suicide risk, especially prior to hospital
    discharge, a change in privileges, or a change in
    clinical status,
  • lack of documentation to reflect a clinical
    rationale regarding treatment decisions, and
  • inadequate patient supervision.

102
Documentation
  • In the case of a lawsuit, the chart will be
    examined.
  • Although most lawsuits arise over inpatients who
    commit suicide, documentation of encounters with
    all suicidal patients should include
  • Risk assessment
  • Contacts with family members
  • Contacts with other treatment providers
  • Phone calls, letters
  • Responses to failed appointments
  • Non-compliance with treatment

103
Risk Management Key Points (Lee Bartlett,
2005)
  • Keep abreast of current legal and ethical
    standards
  • Develop and implement a policy for handling
    crisis situations
  • 24 hour availability of services
  • Increasing frequency or duration of sessions
  • Bring in supportive family/friends
  • Refer where appropriate for multidisciplinary Tx
  • Follow up for compliance and disposition
  • Monitor medication allocation, access, and use
  • Establish check-in system with the client

104
Risk Management Key Points (Lee Bartlett,
2005)
  • Maintain clinical competency (continuing
    education, supervision, consultation)
  • Ensure accurate and thorough documentation
  • Develop relevant resources, such as a network to
    consult with, community programs, etc.

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Postvention
  • Immediately provide support to the family
  • Consider attending funeral or writing letter of
    condolence
  • Serves both humanitarian and risk management
    goals
  • Care for yourself
  • Understand your feelings (guilt, grief, anger,
    fear, etc.)
  • Discuss/consult/debrief with trusted colleague or
    supervisor

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Provider self-care
  • Caring for suicidal patients can be very taxing-
    emotionally and physically!
  • Remember to care for yourself
  • Eat a balanced nutritional diet, get adequate
    sleep, exercise
  • Seek personal counseling formally or informally
  • Consult appropriately with colleagues and
    supervisors
  • May wish to share personal emotional reactions,
    burnout, and counter-transference issues (Shea,
    2002)

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Questions or comments.
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