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Approach to Suicide Risk and Assessment in the ER

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Title: Approach to Suicide Risk and Assessment in the ER


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Approach to Suicide Risk and Assessment in the ER




Resident Presentation
  • March 13, 2003
  • Robbie N Drummond MD

3
OVERVIEW
  • Statistics for our Region
  • Some basic epidemiology
  • Causes of Suicide
  • Risk Factors
  • Psychiatric Illness and Suicide
  • The No Harm Contract and Medico-legal Aspects of
    Suicide
  • A summary of my discussion with Dr. Phil Stokes

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Case 1
  • 39 year old accountant presents with 3 suicide
    attempts in one day
  • sat for 3 hours in car with hose from exhaust
    when it did not work cut wrist and sat in hot tub
    then drank approx 100 ccs methyl chloride paint
    thinner
  • former alcoholic quit x 2 years
  • physical abuse in childhood
  • recently fired from job due to embezzlement of
    funds
  • wife left him suddenly for Ontario with 2
    children
  • when she called said he was safe despite having
    just attempted suicide
  • friend found him
  • evidence of depressed affect on exam
  • foot note CO carboxyhemoglobin stayed high
    despite high fiO2

6
Case 2
  • 21 year old Scandinavian youth
  • aristocratic background presents with agitation
  • says he is not sleeping at nights up pacing on
    the roof of his building
  • cannot concentrate on his studies recently quit
    college
  • feelings of guilt and that he is being punished
  • feeling very down socially isolating himself
    from his family
  • recent stressors sudden death of his father
  • not drinking
  • has hallucinations his dead father telling him to
    kill his uncle who has recently remarried to his
    mother

7
Suicide Note
  • To be, or not to be that is the
    questionWhether 'tis nobler in the mind to
    sufferThe slings and arrows of outrageous
    fortune,Or to take arms against a sea of
    troubles,And by opposing end them? To die to
    sleepNo more and by a sleep to say we endThe
    heart-ache and the thousand natural shocksThat
    flesh is heir to, 'tis a consummationDevoutly to
    be wish'd. To die, to sleepTo sleep perchance
    to dream ay, there's the rubFor in that sleep
    of death what dreams may comeWhen we have
    shuffled off this mortal coil,Must give us
    pause there's the respectThat makes calamity of
    so long life.........

8
Suicide and Depression Emerg Med Cl may 2000
Harwitz
  • Just as a consultation request for a patient
    with complaints of chest pain is more efficient
    when accompanied by a concise history, list of
    medications current vital signs,
    electrocardiogram, blood chemistry and response
    to initial management such is the case in
    referral of a suicidal patient

9
Richard Bukata Emergency Medicine Abstracts 2002
  • The implication of routine consultation in the
    setting of suicide attempts is either that others
    are perceived to know more about assessing
    suicidality than we are or that we want someone
    to agree with us who has some psychiatric
    credentials of some sort. The bottom line is we
    the initially treating physicians are ultimately
    left with the disposition decision.

10
  • A person who is determined to kill himself or
    herself will probably prevail despite the best
    efforts of family members and health care
    professionals, However the overwhelming majority
    of people who decide to kill themselves at one
    time will feel very different after improvement
    in their depression or after receiving help with
    other problems

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Contact with mental health and primary care
providers before suicide Luoma Am J
Psychiatry 2002
  • review of 40 studies
  • 3/4 suicide victims contact with primary care
    providers within year of suicide
  • 45 within one month
  • 1/3 with mental health within one year, 1/5 one
    month
  • especially older patients not so much young men
  • future research re mechanisms of action in
    contacts

20
Suicide Maris The Lancet 2002
  • 1999 deaths by suicide made up 1.2 of all
    deaths in the USA
  • fell steadily from 1990 to 1999 (14 REDUCTION IN
    RATE Over that time suicide had dropped from the
    eighth to the eleventh leading cause of death
  • 30000 deaths per year in USA
  • 18.7 per 100.000 men, 4.4 per 100,000 women
  • lt1 per 100000 in Syria gt40 per 100000 in USSR
  • whites gt2x African Americans
  • third leading cause of death in persons 15 to 34
  • A Current perspective of Suicide and Attempted
    Suicide Mann Ann Int Med 2002

21
Identification of Suicide Risk Factors Using
Epidemiologic Studies Moscicki 1997 psy Cl North
America
  • in USA firearms account for nearly 60 of all
    suicides
  • 10 studies show that a whether handgun or rifle
    in the house even if unloaded increases the risk
    of suicide in adults and youths strongest
    proximal risk factor
  • independently increases the risk of suicide for
    both genders and across all age groups even after
    correcting for confounding factors
  • women drugs medications, second for men
    hanging

22
Assessment and Treatment of Suicidal Patients
Hirschfield NEJM 1997
  • Up to one third of persons in the general
    population have suicidal ideation at some point
    in their lives
  • Physicians are sometimes reluctant to ask
    patients about suicide fearing that the question
    may lead to suicidal thinking and precipitate
    suicidal acts. There is no evidence to support
    this concern
  • Most patients are ambivalent and relieved to talk
  • forecasting the weather vs predicting
    astronomical events
  • predicting short term risk 24 -48 hours more
    reliable than longterm
  • Approximately 25 of suicidal patients do not
    admit to being suicidal (Fawcett et al., 1990).
  • one of eighteen attempts is completed

23
  • suicidal ideation thoughts of ending ones life
  • passive absence of plan I wish I were dead
  • active presence of plan Ive saved my
    medicines.....
  • Suicidal gesture no realistic expectation of
    death
  • suicidal attempt clear expectation of death
  • National Comorbidity Survey
  • suicide ideation to suicide plan were 34
  • plan to attempt were 72
  • transition directly from ideation to an
    unplanned attempt was 26
  • 90 of unplanned and 60 of planned first
    attempts happened within one year of suicide
    ideation

24
Criteria for Screening Diseases WHO
  • 1) the disease is prevalent
  • 2) the disease may not be evident to the person
    who has it
  • 3) the disease is treatable
  • 4) early intervention is advantageous
  • 5) the screening test is reliable
  • 6) the cost and burden of screening is moderate

25
An educational intervention for front-line health
professionals in the assessment and management of
suicidal patients (the STORM project Applebee
Psychological Medicine 2000
  • previous study Morriss et al suicide risk
    assessment and management skills do not change
    without training
  • training delivered to 167 health professionals
    primary care accident and emergency departments
  • 47 of all available staff two training sessions
    in 6 month period
  • non mental health professionals improved
    significantly in assessment, clinical management
    and problem-solving
  • with marked improvement in confidence
  • satisfaction with training was high

26
Teaching Front line health and voluntary workers
to assess and manage suicidal patients Morriss et
al J of Affective Disorders 1999
  • four two hour sessions to 33 health and
    voluntary workers using role-playing,interview
    skill training and video feedback
  • overall risk assessment and management skills
    retained for at least 1 month confidence improved
  • training too brief to produce improvements in
    general interview skills
  • may require up to 6 months to attain

27
Gotland Study
  • education of general practitioners in the
    recognition and treatment of depression in 1983
    was associated with increased antidepressant
    prescriptions and a decrease in the annual
    suicide rate from 20 to 7 per 100,000. The high
    level of medical contact before suicide means
    that effective preventive treatment is possible

28
The Neurobiology of Suicide Risk,Mann J Cl Psych
1999
  • genetic modulation of serotonergic activity
  • aggression and impulsivity changes found in
    substance abuse and depression
  • 18 studies look a 5 hydroxyindoleactic acid 5HIAA
    in CSF
  • low levels in suicide attempters
  • the more lethal the attempt the lower the level
    of 5 HIAA
  • gene for tryptophan hydroxylase is affected
  • altered serotonin function lack of serotonin
    transporter binding in nerve terminal
  • changes in prolactin responses to serotonin
    responsivity
  • increased serotonin receptors on platelets
  • PET scanner shows significant reduction of
    resting glucose metabolism in prefrontal cortex
    of murderers and skewed serotonin circuitry in
    suicidal patients
  • suicidal patients have higher serum cortisol
    levels

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Genetics of Suicide in Depression Roy et al J
clin Psych 1999
  • 11 of completed suicides had another first
    degree relative who had committed suicide
    (Hemmingway family grandfather, father, son,
    granddaughter)
  • significantly more in a patient that had made a
    violent attempt
  • genetic transmission of psychiatric disease
  • twin and adoption studies high concordance for
    suicide rates
  • of 35 twins for whom 1 twin had committed suicide
    10 of the 26 living monozygotic twin had
    attempted compared to 0 of the dizygotic twins
  • significantly more of adopted children of
    biological parents who committed suicide
    themselves committed suicide Copenhagen study
  • genetic susceptibility to suicide only likely to
    manifest in times of severe stress or when ill
    with major psychiatric illness
  • heritable trait analogous to other disorders
    e.g. bipolar

31
Childhood Abuse, Household Dysfunction and the
Risk of Attempted Suicide Throughout the Life
Span Dube et al JAMA 2001
  • well designed study 9367 women, 7970 men
  • retrospective cohort study of 17,337 adults HMO
    members
  • survey of childhood abuse household dysfunction
    and suicide attempts
  • lifetime prevalence of 1 suicide attempt 3.8
  • adverse childhood experiences increased the risk
    2 -5 fold
  • emotional, physical and sexual abuse, household
    substance abuse, mental illness, and
    incarceration, and parental domestic violence,
    separation, or divorce
  • as number of adverse experiences increase the
    risk increses dramatically
  • 67 of suicide attempts are attributable to
    traumatic childhood experiences

32
5 Questions
  • do you ever get so depressed that you think life
    is not worth living?
  • do you think of hurting yourself or taking your
    own life?
  • do you have a plan?
  • do you have the means to follow through with the
    plan?
  • have you ever attempted suicide?

33
Demographic Risk Factors
  • gender women three times as likely to attempt men
    four times as likely to die
  • race whites and native Americans
  • age 60 years and older
  • leading cause of death in 10 to 49 years old in
    our region
  • lack of social support unmarried divorced or
    widowed
  • financial difficulties unemployment
  • the risk factors for suicide are additive

34
nontraditional risk factors
  • drinking within three hours of the suicide
    attempt
  • changing residences within the past 12 months
  • existing medical conditions
  • impulsive behavior
  • 50 of people who died by suicide in Chicago had
    no close friends the presence of of a therapist,
    spouse, or other person (only one other person)
    is crucial
  • the difficulty with risk factor for suicides is
    that they lead to many false positive predictions

35
SAD PERSONS a mnemonic for assessing suicide risk
  • S Sex (male)
  • A Age (elderly or adolescent)
  • D Depression
  • P Previous suicide attempts
  • E Ethanol abuse
  • R Rational thinking loss (psychosis)
  • S Social supports lacking
  • O Organized plan to commit suicide
  • N No spouse (divorced gt widowed gt single)
  • S Sickness (physical illness)
  • Adapted from Patterson et al (12).
  • 0 -3 close follow up consider admit, 4 -5
    consider admit, gt5 admit

36
No Hope Scale
  • N No framework for meaning
  • O Overt change in clinical condition
  • H Hostile interpersonal environment
  • O Out of hospital recently
  • P Predisposing personality factors
  • E Excuses for dying are present and strongly
    believed
  • only three scales have predictive validate Becks
    hopelessness scale, Linehans reasons for living
    and Cull and Gills suicide probability scale
  • no one psychological test is highly predictive of
    suicidal acts
  • Risk factors fall into 2 categories predisposing
    factors and potentiating factors
  • the combination of psychiatric disorder and a
    stressor

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The best predictor of completed suicide is a
history of attempted suicide
  • subsequent attempts greater lethality and intent
  • careful inquiry about past suicide attempts
    essential part of tisk assessment
  • two thirds of suicides occur with first attempt
  • the greatest risk occurs within 3 months of the
    first attempt

40
Suicide after Parasuicide Runeson BMJ 2002
  • The risk of suicide is generally most prominent
    during the first months after psychiatric care
  • The risk of repetition and consequently of
    suicide is believed to be highest during the
    first one or two years after an episode of
    parasuicide
  • the initial high risk declines each year

41
Suicide rate 22 years after parasuicidecohort
study Jenkins BMJ 2002
  • The rate of suicide for people who have had an
    episode of parasuicide is 100 times higher in the
    year following the episode than that of the
    general population
  • traced record 22 years 63 of the original sample
  • the risk of suicide for people with a history of
    parasuicide persists over many years 4.3 per 1000
    per year gt 3 x normal rate

42
More than 90 of suicide victims have a
diagnosable psychiatric illness
  • main protective factors accurate, early diagnosis
    and effective treatment of psychiatric disorders
  • important to be aware of Axis formulation
  • Axis 1 major psychiatric disorder including
    substance abuse
  • Axis 2 personality disorder including impulsivity
    and aggressivity
  • Axis 3 major contributing physical illness esp
    in elderly
  • Axis 4 recent major stressors
  • Axis 5 highest level of functioning which would
    include withholding factors
  • Axis 1, 2, and 3 predisposing factors Axis 4, and
    5 potentiating

43
Risks depending on diagnosis
  • 60 have mood disorders
  • followed by schizophrenia, alcoholism, substance
    abuse and personality disorder
  • most people with psychiatric disorder never
    attempt suicide
  • lifetime risk
  • Bipolar 20
  • alcoholism 18
  • major depression 15
  • schizophrenia 10
  • borderline and antisocial personality disorder
    5-10

44
Depression Screening as an Intervention Against
Suicide Jacobs J clin Psychiatry 1999
  • prevalence of current major depression has been
    estimated 4.9
  • lifetime prevalence is 17.1
  • less than 40 of lifetime depression are
    diagnosed
  • less than 20 current depression were in
    treatment
  • national depression screening day 30 sites malls
    libraries corporations army bases hospitals
    started Quincy Mass
  • October during Mental Illness Awareness Week
  • Zung Self Rated Depression Scale
  • 400,000 screened followed by one on one interview
    and referral
  • 20 found to have severe depression 1444
    hospitalized
  • only 15 of a sample of individuals who killed
    themselves had received antidepressant medication
    in New York 84 of a sample of people who
    committed suicide had not taken any
    antidepressant or neuroleptics Maris the Lancet
    2002

45
SIG ME CAPS (prescribe me caps)
  • Usually one uses either the Hamilton or Beck
    depression inventory or scale, since suicide
    outcomes correlate highly with depressive
    disorders
  • five symptoms to make diagnosis in 2 week period
  • S sleep
  • I interest
  • G guilt
  • M mood
  • E energy
  • C concentration
  • A appetite
  • P psychomotor retardation or agitation
  • S suicidal ideation

46
  • hard to find conclusive evidence of the syllogism
    that clinical depression is the leading cause of
    suicidal behaviour, that depression is highly
    treatable and adequate treatment should reduce
    suicide risk
  • however statistics in USA show decline likely due
    to increased awareness and use of newer
    antidepressants

47
Suicidality and Substance Abuse in Affective
Disorders Goldberg J CLin Psych 2001
  • 5- 10 fold increase
  • more medically dangerous attempts
  • abuse higher in bipolar than any other Axis 1
    diagnosis
  • alcohol worsens the course of all affective
    illnesses
  • 56 male bipolar suicide are alcoholic
  • impulse control disorders 40 alcohol dependence
  • likely higher levels of aggression
  • greater levels of panic disorder, phobic
    disorders and GAD
  • serotonin dysfunction implicated
  • impulsivity, aggression, alcohol dependence,
    suicide and affective disorders

48
up to 50 of all people who commit suicide are
intoxicated at the time of death 18 of
alcoholics will die by suicide
  • increases brain serotonin at first depletes later
  • reduces impulse control
  • adolescent suicide victims with alcohol abuse
    more vulnerable to interpersonal losses and
    psychosocial stressors
  • social isolation and alcohol abuse linked to
    suicide middle-aged men
  • SSRIs diminish alcohol symptoms as well as
    depressive features in depressed alcoholics with
    suicidality
  • specific psychotherapies cognitive behavioral
    therapies, dialectical behavioral therapy
    effective in borderline personality, alcoholism,
    depression
  • Intoxicated or psychotic patients unknown to
    clinician who say they are suicidal should be
    transported securely to the nearest crisis
    center. These patients can be dangerous and
    impulsive.

49
Personality Traits
  • more subjective depression and hopelessness
  • greater lifetime aggressively and impulsivity
  • patients with a history of violence greater
    lifetime risk of self harm
  • personality based suicide results from feelings
    of anger aggression or vengeance
  • psychoanalyst says adamancy is main trait

50
Chronic suicidality among patients with
borderline personality disorder Paris J
Psychiatric Serv June 2002
  • One in ten completes suicide
  • not preventable usually does not occur in
    treatment
  • chronic suicidality a way of communicating
    distress
  • hospitalization unproven benefit possible
    negative effects
  • fear of litigation not a reason to admit
  • suicide risk not a contraindication for OPD
    treatment

51
Characteristics of suicide attempts of patients
with major depressive episode and borderline
personality disorder a comparative study. Soloff
PH Am J Psych Apr 2000
  • Co morbidity of borderline personality disorder
    with major depressive episode increases risk
  • Hopelessness, impulsive aggression increase risk
    in both patients with borderline personality
    disorder and in patients with major depressive
    disorder
  • The same combination of biologic and
    psychodynamic factors that can render these
    persons unpleasant to treat are also those that
    place them at risk for repeated and possibly
    fatal injury to themselves. ED staff should be
    equipped to tolerate and manage such behaviour
    until the patient is medically stable and
    appropriate follow-up consultation with
    psychiatry is arranged

52
Advanced Techniques of Interviewing, Craig 1996
Suicidality in Psychotic Patients
  • small but significant number of people who
    attempt suicide are actively psychotic
  • any evidence of psychosis warrants a thorough
    evaluation of lethality
  • three particular areas command hallucinations,
    feelings of alien control, and hyper religiosity
  • recent evidence many schizophrenics more likely
    to commit suicide in remission when they are apt
    to feel depressed and hopeless
  • demographic factors are relevant
  • recent losses and poor support systems
  • alcohol drugs or any physiologic insult to the
    CNS
  • interview corroborative informants

53
Suicide in Teenagers Zametkin JAMA 2001
  • rate of suicide among adolescents has
    significantly increased in past 30 years
  • less likely less than twelve
  • however 170 children aged 10 or younger commit
    suicide each year
  • same risk factors in addition male greater than
    16, living alone, history of physical or sexual
    abuse,substance abuse
  • high percentage of suicidal ideation 27 in
    teenaged population
  • Less specific Alarming Factors
  • recent dramatic personality change
  • psychosocial stressor (trouble with family or
    friends or a disciplinary crisis)
  • writing thinking or talking about death
  • altered mental status (agitation hearing voices,
    delusions, violence, intoxication

54
  • No proof yet that gay and lesbian youth higher
    proportion of suicide deaths (higher rates of
    substance abuse and mental disorder)
  • adolescents are generally not compliant with
    psychiatric treatment
  • two studies up to 50 removed from therapy for
    not attending
  • suicide attempters ended therapy earlier than
    nonsuicidal children
  • good evidence that unipolar and bipolar disorders
    in adolescents is essentially identical to that
    in adults
  • efficacy of antidepressants in a teenage
    population
  • adult doses of SSRIs

55
  • suicide risk is highest at the beginning of a
    depressive episodes
  • suicide awareness programs in schools have not
    been effective either in reducing suicidal
    behaviour or in increasing help seeking behaviour
  • no clear criteria for hospitalizing and
    discharging a patient at moderate risk for
    suicide
  • hospitalization for altered mental
    status,actively abused substances,recently
    attempted suicide, experience hopelessness or
    impulsivity, lack of parental supervision

56
Disease as Risk Factor
  • increased suicide risk with immobility ,
    disfigurement, or severe pain
  • evidence of hopelessness or helplessness
  • hostile interpersonal environment may increase
    risk
  • strong framework of meaning decreases risk
  • sudden change in clinical condition either
    positive or negative may indicate an increased
    risk
  • cigarette smoking
  • Barraclough HIV, Huntingtons malignant
    neoplasms, MS, PUD, renal disease (esp dialysis
    patients) spinal cord injuries and SLE all
    associated with psychiatric illness

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Pharmacological Interventions in Suicide
Prevention Tondo et al. J clin Psych 2001
  • depressive disorders respond quickly to ECT can
    take 4-6 weeks for response to meds
  • other therapies conjoint cognitive psychotherapy,
    dialectical behavioral therapy or behaviour
    modification techniques
  • TCAs, MOAIs, SSRI's inconsistent effect on
    suicide risk
  • antipsychotics uncertain effect suicide risk
    (akithisia from older drugs haldol and
    fluphenazine may have contributed to some
    suicidal attempts)
  • newer atypical antipsychotics (clozapine et al)
    lower rate of life threatening suicide attempts
    in schizophrenics

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  • Lithium has been shown to consistently reduce
    risk of suicide in pts with bipolar disorder
  • prophylactic unrelated to mood stabilizing effect
  • may be beneficial in unipolar depression as well
  • discontinuation of lithium maintenance sharp
    increase in suicide risk
  • carbamazepine less effective than lithium in
    preventing suicide
  • benzodiazepines may modify the risk of suicide by
    reducing anxiety
  • anxiety and insomnia associated with completed
    suicide these symptoms should be treated quickly

61
Deliberate self harm systematic review of
efficacy of psychosocial and pharmacological
treatments in preventing repetition Hawton et
al BMJ 98
  • 20 randomized trials in Cochrane data base that
    looked at effectiveness of treatment randomized
    controlled trails metaanalysis
  • some benefit with low statistical power for
  • 1) problem solving therapy
  • 2) provision of emergency contact card
  • 3) intensive aftercare, plus outreach
  • 4) antidepressant treatment compared with placebo
  • 5) significantly reduced rates for multiple
    repeaters for depot flupentixol

62
Assessment of Suicide Risk 24 Hours After
Psychiatric Hospital Admission Russ et al
Psychiatric Services 1999
  • some evidence that acute hospitalization is not
    effective in reducing risk
  • small sample size
  • of 69 patients 30 44 were found to be completely
    free of suicidal ideation 24 hours after
    admission
  • pts who recently made an attempt less likely to
    have ideation 24 hours later
  • did not suggest changes
  • wondered about refinement of tools to identify
    patients who might benefit from rapid assessment
    and referral to treatment in community
  • No evidenced based data that psychiatric
    hospitalization prevents immediate or eventual
    suicide
  • in one study parasuicidal adult patients
    randomized to home or hospital no significant
    difference was found in outcome as measured by
    subsequent suicide or general functioning

63
In the Final Analysis....
  • Patients with a plan, access to a lethal means,
    recent social stressors and evidence of a
    psychiatric disorder should be hospitalized.

64
The No Harm Contract in the Emergency Assessment
of Suicidal Risk Stanford et al J clin Psych 94
  • no studies that meet criteria for scientific
    research design
  • review of use since 1973
  • Suicidal patient is asked to agree not to harm or
    kill herself or himself for a particular period
    of time
  • the patient may 1) agree with this proposal
    verbally or by signing written statement, 2)
    suggest modifications, 3) refuse compliance, or
    4) choose not to answer
  • 1979 1980s Goulding characterized NHCs as a
    high priority tool
  • by the 1980s firmly established in the
    literature minimal empiric base

65
Diagnostic and Therapeutic Uses
  • within the time constraints of the busy ER can
    help to crystallize the physicians understanding
    of the patients mental state
  • how the patient responds more critical than what
    the contract states
  • therapeutically establishes alliances if
    presented in a caring and a careful way clear
    limits set accountability on patients part
  • opportunity for patient to reflect immediate
    sense of relief by their being able to contract
    for safety in a limited time frame
  • in patients who resist confrontation and
    clarification possible
  • therapeutic for physician relieves anxiety

66
medicolegal issue
  • 1) patient often does not meet threshold legal
    criteria for competence\
  • 2) no valuable consideration given
  • 3) no mutual obligation beyond NHC
  • 4) exculpatory clause for physician contravenes
    public policy

67
misuses
  • inappropriate disposition
  • replace complete evaluation
  • replace comprehensive treatment planning
  • attempt to prevent malpractice suit
  • inappropriately reassure patient and staff
  • when a NHC is used documentation should show
    thorough diagnostic assessment thorough risk
    factor analysis and risk benefit analysis of
    hospitalization along with measure of patients
    competency
  • used in context of of structured suicidal risk
    evaluation

68
Use of No-Suicide Contracts by Psychiatrists in
Minnesota. Kroll, J Am J Psychiatry 2000.
  • The Study
  • Postcard questionnaire mailed to 514
    psychiatrists in Minnesota
  • There was a 52 response rate.
  • 57 of the psychiatrists used no-suicide
    contracts 62 verbal only, 38 written
  • 77 of psychiatrists had used contracts b/c they
    thought it was helpful 23 used them, but
    thought they were not helpful.
  • 41 of the psychiatrists had patients who had
    committed suicide/ made a serious suicide attempt
    after making the contract.

69
The Suicide prevention contract clinical, legal
and risk management issues Simon RI J Acad Psych
Law Jan 2000
  • The suicide prevention contract is not a legal
    document that will exculpate the clinician from
    malpractice liability if the patient commits
    suicide. The contract against self-harm is only
    as good as the underlying soundness of the
    therapeutic alliance. The risks and benefits of
    suicide prevention must be clearly understood
  • Suicide prevention contracts are clinical
    contracts. They have no legal force (Simon,
    1999). There are no studies that demonstrate
    suicide prevention contracts are effective in
    reducing suicide.Reliance on a suicide
    prevention contract may falsely reassure the
    clinician and lower vigilance, possibly
    increasing the risk of suicide

70
CMPA
  • Number one cause of malpractice suits against
    psychiatrists
  • between 1996 and 2000 there were 242 closed legal
    actions against EDs
  • seven percent involved psychiatric problems (no
    breakdown)
  • same time frame 221 closed legal actions for
    psychiatrists
  • 19 percent represented patients who attempted or
    committed suicide
  • represented 25 of the costs for the
    psychiatrists

71
  • of the cases involving suicide 25 were lost
    either settled or at trial
  • a physician can be defended if there is adequate
    assessment and documentation
  • the medico legal risk involves either a failure
    to recognize risk or failure to supervise and
    protect the patients

72
Suicide and LitigationLessons Learned in Risk
Management Simon, Psych Times Sept 2002
  • Suicides account for the largest number of
    malpractice suits filed against psychiatrists, as
    well as the highest percentage of settlements and
    verdicts paid by malpractice carriers
  • No standard of care exists for the prediction of
    suicide. A standard of care does exist requiring
    psychiatrists to adequately assess suicide risk
    when it is clinically indicated
  • The assessment of suicide risk is an informed
    clinical judgment call, not a prediction. A risk
    of suicide, rather than a suicide itself, is
    foreseeable Foreseeability is not the same as
    predictability, for which no professional
    standards exist.
  • In the case of a lawsuit, the chart will be
    examined to determine whether the physician
    recognized the risk factors and considered the
    benefits of exerting greater control over the
    patient (e.g. Hospitalization, calling the
    family)
  • occasionally , patients may not allow the
    clinician to contact their families. When
    someones life is in imminent danger,
    confidentiality may be breached.

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Documentation
  • if not documented not done
  • because suicide risk and ideation complex needs
    more documentation
  • no-harm contracts not a substitute
  • well-documented suicide risk assessments provide
    a solid legal defense
  • A review of records in psychiatric malpractice
    cases often reveals the following Patient denies
    SI/HI, CFS (no suicidal ideation or homicidal
    ideation, contracts for safety) or, at most,
    "Patient denies suicidal ideation, intent or plan

74
Need
  • 1) description of suicide ideation and lethality,
  • 2) risk factors
  • 3) past medical and psychiatric history (meds)
  • 4) basic formulation of psychiatric illness,
  • 5) history of substance abuse,
  • 6) family history
  • 7) previous attempts,
  • 8) access to lethal means,
  • 9) social support structures
  • 10) clear delineation of therapeutic
    interventions put in place

75
Discussion with Dr Phil Stokes head of Ambulatory
Psychiatry at PLC
  • Says we do a very good job at assessing these
    patients
  • suicidal ideation is common suicide is relatively
    rare
  • important to balance plans and ideation with
    withholding factors
  • command voice in psychotic patients a high risk
    factor
  • balance seriousness of medical risk against
    seriousness of intent
  • important to get collateral information can break
    confidentiality ask permission first
  • assess demographics carefully SADPERSONS e.g.

76
  • borderline personality disorder 10 overall but
    odds of episode 54 very small. Most important
    factor is there regular follow-up?
  • ED assessment should take 15 minutes need to
    assess basic risk factors get basic history
    clarify diagnosis. Full mental status (especially
    if referral probable) will likely be duplicated
  • form 1 should almost always be assessed by
    psychiatrist unless signed when patient was
    severely intoxicated and the next day is sober
    judgement called for
  • missed suicide is the most likely cause for
    lawsuit for psychiatrist not true for primary
    care physicians.Psychiatrists are the suicide
    experts and their expertise exposes them to
    liability

77
Case 1
  • White male
  • history of alcoholism (not drunk at time)
  • history of childhood abuse
  • possible symptoms of major affective disorder
  • no previous attempt
  • serious attempt with attempt to deceive
  • major psychosocial stressors loss of job, marital
    separation
  • was admitted to short term assessment unit at PLC

78
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79
Poster Boy for Prozac
  • Risk factors male, in adolescent period, white,
    decreased social withholding factors,
  • clear signs that he is suffering from major
    affective disorder depression
  • suicidal ideation even intent
  • recent major stressors has dropped out of school
    murder of his father
  • no evidence of substance abuse
  • most concerning command hallucinations suggest
    possible psychotic features
  • call the crisis team
  • form 1......direct admit to psychiatry....cancel
    acts II -V

80
The Rest Is Silence.......
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