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Suicide Risk Assessment

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Title: Suicide Risk Assessment


1
Suicide Risk Assessment
  • A Brief Introduction for Helpers

Updated 19-09-13
2
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SERENITYPROGRAM
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3
18 September 2013  Global economic crisis 'linked
to suicide rise'
Researchers from the universities of Oxford and
Bristol in the UK, along with colleagues from
Hong Kong University, used data from the World
Health Organization mortality database, the
Centers for Disease Control and Prevention and
the International Monetary Fund's World Economic
Outlook database. In 2009, there was a 37 rise
in unemployment and 3 falls in GDP per capita,
reflecting the onset of the economic crisis in
2008. There were nearly 5,000 'extra' suicides
above the expected level for that year. The
financial crisis "almost certainly" led to an
increase in suicides across Europe, health
experts say. The analysis by US and UK
researchers found a rise in suicides was recorded
among working age people from 2007 to 2009 in
nine of the 10 nations studied. The increases
varied between 5 and 17 for under 65s after a
period of falling suicide rates, The Lancet
reported.
4
2 May 2013  Suicides soar among US middle-aged
people
The suicide rate among middle-aged Americans rose
28 in a decade, a new report from the Centers
for Disease Control (CDC) has found. Since 2009,
suicide has claimed more Americans than motor
vehicle crashes. There were 38,350 suicides in
2010, making it the nation's 10th leading cause
of death, the CDC said.
5
7 September 2013  Suicides cost Japan economy
32bn
The government in Japan says suicides and
depression cost its economy almost 2.7tn yen
(32bn 21bn) last year. The figures refer to
lost incomes and the cost of treatment. It is the
first time Japan has released such
figures. Japan has one of the world's highest
suicide rates, with more than 32,000 people
killing themselves last year. PM Naoto Kan sees
it as proof of an economic and emotional
downturn. In a country in which stoicism and
consensus are highly valued, many older people in
particular view mental illness as a stigma that
can be overcome simply by trying harder, they
say. The use of psychotherapy to treat
depression has lagged behind North America and
Europe, with Japanese doctors often viewing
medication as the sole answer, they add.
6
18 September 2013  One in three 'behind on rent'
since housing benefit changes
One in three council tenants affected by a recent
cut to housing benefit has fallen behind on rent
since the policy took effect, figures suggest.
The TUC's False Economy campaign made Freedom of
Information requests to all of Britain's
councils 114 responded. Data revealed 50,000
tenants had fallen into arrears since 1 April
2013 when the housing benefit changes came in - a
move critics called the bedroom tax. The council
with the greatest percentage of tenants who had
fallen behind was Barrow in north-west England.
Of the 289 tenants there affected by the cut, 219
have not been able to pay rent since the policy
came into effect. The National Housing
Federation has also carried out a survey looking
at the numbers of tenants in arrears. It found
that a quarter of households affected by the cut
have fallen behind in their rent for the first
time ever - 11,000 out of 44,000 households were
in arrears according to data given by 38 of
England's housing associations.
7
Introduction
  • This is not meant to be a detailed guide to the
    specialised area of suicide prevention or suicide
    risk assessment
  • This presentation provides an introduction to the
    subject of recognising and intervening safely
    with clients who may present a risk of suicide
  • It is intended for volunteer helpers to support
    their work with the Serenity Programme

8
Contents
  • Recognising depression
  • Typical thought and speech patterns of people at
    risk of suicide
  • A semi-structured interview for risk assessment
    (Meichenbaum)
  • Factors associated with suicide risk
  • Risk and protective factors
  • The PALS assessment
  • Additional resources SBQ-R, Pierce, PHQ-9 etc.

9
Depression prevalence
  • Depression is the fourth leading cause of
    disability and disease worldwide
  • It is estimated that depression will become the
    second most common cause of disability, after
    heart disease, by 2020
  • Unipolar forms of depression are more common in
    women than men. In Britain 3-4 of men and 7-8
    of women are thought to suffer from moderate to
    severe depression at any one time
  • The incidence of dysthymia (sub-threshold
    depressive symptoms persisting for more than
    2 years) increases with age 2.55 of people
    will experience dysthymia during their lifetime
    (Waraich et al, 2004)

10
Types of depression
  • Major depressive disorder diagnosed by the
    person feeling 5 or more of the symptoms of
    depression, lasting over 2 weeks
  • Adjustment disorder milder and shorter-lived
    forms of depression, often resulting from
    stressful experiences
  • Dysthymia long-term symptoms of depression (of
    at least 2 years) which are not severe enough to
    meet criteria for major depression
  • Post-natal depression occurs after childbirth
    (also peri-natal depression, which can occur
    during pregnancy but which is less common)
  • Seasonal Affective Disorder (SAD) depression
    associated with lack of daylight and shorter
    daylight hours in winter
  • Bipolar disorder (sometimes called manic
    depression)

11
Recognising depression (1 of 2)
  • Symptoms of depression can appear over a period
    of months or years or in the case of bipolar
    disorder, suddenly and escalate over just a few
    days
  • In diagnostic terms, 5 of the following should be
    present during the same 2-week period and have
    caused a change from previous functioning
  • For a major depressive episode, symptoms must
    appear on a daily basis and last most, or all of
    the day

12
Recognising depression (2 of 2)
  • Depressed mood (sad, hopeless or empty)
  • Markedly diminished pleasure in all (or almost
    all) activities
  • Insomnia or hypersomnia
  • Increase or decrease in appetite or significant
    weight loss
  • Fatigue or loss of energy
  • Feelings of worthlessness
  • Excessive or unwarranted guilt
  • Diminished ability to think, concentrate or take
    decisions
  • Recurrent thoughts of death, suicidal ideation,
    having a suicide plan or making a suicide attempt

13
Antidepressants
  • Antidepressants can be very effective in helping
    people recover from depression but can also be
    used to attempt suicide through overdose. There
    is no clear evidence to show that they reduce
    suicide or self harm
  • Selective Serotonin Reuptake Inhibitors (SSRI)
    are thought to cause suicidal thoughts and
    behaviour in some people. Current research
    suggests that this is true for children and
    adolescents but there is currently no evidence to
    support the heightened suicide risk in adults
  • There may be a period of increased risk if
    motivation to act improves before mood

14
Suicide risk
  • For people with severe depression, the lifetime
    risk of suicide may be as high as 6, compared
    with a risk of 1.3 in the general population
  • For those with bipolar disorder, suicide risk is
    15 times that of the general population

15
Suicide risk assessment
  • Is, in itself, treatment
  • Takes place in an empathic, therapeutic
    relationship
  • Is unique for each individual
  • Is complex and challenging
  • Is an ongoing process
  • Errs on the side of caution
  • Is collaborative and relies on effective
    communication
  • Relies on clinical judgement
  • Takes all threats, warning signs, and risk
    factors seriously
  • Asks the tough questions
  • Tries to uncover the underlying message
  • Is carried out in a culturally-sensitive manner
  • Is well documented

Adapted from Meichenbaum, D.
16
Thinking patterns (1 of 2)
  • Dichotomous (either-or) thinking
  • Cognitive rigidity and constriction
  • Perfectionistic standards toward self and others
    with high levels of self-criticism
  • Lack of specificity in autobiographical memory,
    overgeneral and vague memory interferes with
    problem-solving because past cannot be used as
    references for coping in the present
  • Low confidence in problem-solving ability
  • Looming vulnerability - the perceived
    experience of negative occurrences as rapidly
    escalating, quickly approaching adversities that
    generate distress

17
Thinking patterns (2 of 2)
  • Hopelessness and helplessness with negative
    expectations about the future
  • Ruminative process feeling cornered, unable to
    consider alternatives
  • Present-oriented and view death in a relatively
    favourable light
  • Difficulty generating reasons for living
  • Absence of protective factors such as attraction
    to life, repulsion by death, surviving and coping
    beliefs, sense of personal self-efficacy, moral
    and religious objections to suicide, fear of
    self-injury and sense of responsibility to family

18
Characteristic speech content (1 of 3)
  • I can't stand being so depressed anymore I am
    damaged goods (Intractable emotional pain)
  • Suicide is the only choice I have left (Only
    one or two choices dichotomous thinking)
  • My family would be better off without me I am
    worthless. They would be better off if I were
    dead I am worth more dead than alive
    (Perception of being a burden on others)
  • I am useless and unwanted (Feel unattached,
    perceive others as uncaring and unsupportive
    feel socially disconnected and lack emotional
    intimacy)
  • No one cares whether I live or die (Feel
    rejected, marginalised, worthless, unlovable,
    isolated, alone, a failure)
  • I am worthless and dont deserve to live (Guilt
    and shame)
  • I am a bad person, I have to escape (Escape
    from self)

19
Characteristic speech content (2 of 3)
  • I feel I am crashing, like a freight train or
    like a wave has hit me. There is no hope. Whats
    the point? (suicidal individuals are prone to
    produce elaborate mental scenarios anticipating
    rapidly rising risk with multiply increasing
    threats. Tend to exaggerate the time course of
    perceived catastrophic outcomes and have an
    increased sense of urgency for escape and
    avoidance)
  • I hate myself (Suicidal individuals have an
    over-generalised memory and tend to selectively
    recall negative events that contribute to
    self-loathing)
  • I cant fix it, I should just die (Tunnel
    vision, inflexibility in generating alternatives,
    feeling trapped and perceived inescapability)

20
Characteristic speech content (3 of 3)
  • I would rather die than feel like this forever
    (Low distress tolerance and inability to consider
    future possibility of change)
  • I have lost everything important to me My life
    is empty Life is not worth living Nothing
    will change Whats the point? My life has no
    purpose (Helplessness, hopelessness and
    meaninglessness)
  • I have screwed up, so I might as well screw up
    all the way (when in a hole keep digging)
  • Theyll be sorry They will miss me when Im
    gone (post-mortem revenge)

21
Very High Risk Seek immediate professional help
High Risk Seek professional help
Lower Risk Monitor for development of warning
signs
Adapted from Rudd et al, 2006
22
What would you do if
  • A client calls you on the telephone saying they
    are going to kill themselves
  • What would you want to know?
  • Work first individually, then as a group

23
Risk Protective Factors
Relationships Hope Faith Work
Loss Depression Hopelessness Impulsivity
Protective factors may not mean just the
presence of something it may also mean the
absence of something for example, the absence
of access to means of suicide
24
Factors associated with risk (1 of 3)
  • Direct indices of imminent risk for suicide or
    parasuicide
  • Suicide ideation
  • Suicide threats
  • Suicide planning and or preparation
  • Parasuicide in last 12 months

Adapted from A social-Behavioral Analysis of
Suicide and parasuicide Implications for
Clinical Assessment and Treatment by M.M.
Linehan (1981), in H. Glaezer J.F. Clarkin
(eds.), Depression Behavioral and Directive
Intervention Strategies. New York Garland
25
Factors associated with risk (2 of 3)
  • Indirect indices of imminent risk for suicide or
    parasuicide
  • Client falls into suicide or parasuicide risk
    populations
  • Recent disruption of loss of relationship
  • Negative environmental change in last month
  • Recent hospital discharge
  • Indifference to, or dissatisfaction with therapy
  • Current hopelessness, anger or both
  • Recent medical care
  • Indirect references to own death, arrangements
    for death
  • Abrupt clinical change, either negative or
    positive

26
Factors associated with risk (3 of 3)
  • Circumstances associated with suicide or
    parasuicide in next several hours or days
  • Depressive turmoil, severe anxiety, panic
    attacks, severe mood cycling
  • Alcohol or drug use
  • Suicide note written or in progress
  • Availability of methods
  • Isolation
  • Precautions against discovery or intervention,
    deception or concealment about timing, place etc.

27
PALS - Proximity to others
  • P Proximity to Others
  • How isolated is the client? Are there any
    significant others around who might be potential
    rescuers and interfere or otherwise foil the
    clients plan?
  • Can others be encouraged to actively defuse the
    clients plan - e.g. hide guns or confiscate
    pills?
  • Clients with few significant relationships are at
    higher risk

28
PALS - Proximity to others
  • Which plan below is most likely to be foiled by
    others?
  • A. I am going to go into the girls toilets at
    school and take an overdose
  • B. I am going to wait till my parents have left
    for work and then go into the basement and slash
    my wrists
  • C. I am going to go to my boyfriend's house
    during his birthday party and hang myself in his
    backyard

29
PALS - Proximity to others
  • Which plan below is most likely to be foiled by
    others?
  • A. I am going to go into the girls toilets at
    school and take an overdose (possible answer
    toilets are public places)
  • B. I am going to wait till my parents have left
    for work and then go into the basement and slash
    my wrists
  • C. I am going to go to my boyfriend's house
    during his birthday party and hang myself in his
    backyard (very high likelihood of intervention by
    others)

30
PALS - Availability of means
  • A How accessible is weapon or means of self
    harm?
  • Does the client have a gun, knife, pills etc. in
    his or her possession?
  • Do they have to steal, borrow or purchase them?
  • How easily can means of self harm be obtained?
  • Means of self harm already in clients possession
    are most risky

31
PALS - Availability of means
  • Which of the means below is most accessible?
  • A. I have got a large carving knife stashed in
    the back of my bottom drawer
  • B. I am going to get my psychiatrist to write me
    a large prescription for barbiturates
  • C. I am going to go out on the street and find a
    drug dealer who will sell me a large dose of
    heroin

32
PALS - Availability of means
  • Which of the means below is most accessible?
  • A. I have got a large carving knife stashed in
    the back of my bottom drawer (readily available
    nearby)
  • B. I am going to get my psychiatrist to write me
    a large prescription for barbiturates
  • C. I am going to go out on the street and find a
    drug dealer who will sell me a large dose of
    heroin (Both B C rely on the cooperation of
    others to obtain the means)

33
PALS - Lethality of means
  • L Lethality of Means
  • How precipitous is the method of self harm? Once
    started can the method be reversed?
  • Guns, jumping from great heights and jumping in
    front of moving vehicles are highly lethal
  • Cutting and overdoses may be relatively less
    lethal because people might be able to can change
    their minds
  • Precipitous methods in a plan are more serious
    and more lethal

34
PALS - Lethality of means
  • Which of the means below is least likely to be
    harmful?
  • A. I am going to get my husband's loaded revolver
    and blow my brains out
  • B. I am going to jump off a the bridge over the
    A55 at 5 oclock
  • C. I am going to take a whole bottle of
    antibiotics left over from my last urinary track
    infection

35
PALS - Lethality of means
  • Which of the means below is least likely to be
    harmful?
  • A. I am going to get my husband's loaded revolver
    and blow my brains out (very precipitous and
    lethal)
  • B. I am going to jump off a the bridge over the
    A55 at 5 oclock (highly lethal)
  • C. I am going to take a whole bottle of
    antibiotics left over from my last urinary track
    infection (antibiotics are not usually lethal in
    overdose)

36
PALS - Specificity of plan
  • S Specificity of Plan
  • How detailed is the clients plan?
  • Have they thought of a place, time or deadline
    for the act?
  • Have they made special arrangements to make the
    plan work?

37
PALS - Specificity of plan
  • Which plan below is most specific and therefore
    most risky?
  • A. I am going to hurt myself so my partner will
    appreciate me more
  • B. I am going to drive my father's new car off a
    bridge on my parent's anniversary next week!
  • C. I am going to get a prescription of pills and
    take them when no one is around

38
PALS - Specificity of plan
  • Which plan below is most specific and therefore
    most risky?
  • A. I am going to hurt myself so my partner will
    appreciate me more? (neither method, time nor
    place specified)
  • B. I am going to drive my father's new car off a
    bridge on my parent's anniversary next week?
    (method, time and deadline specified)
  • C. I am going to get a prescription of pills and
    take them when no one is around? (what kind of
    drug, how will they get it and when will it be
    taken?)

39
Care
  • PALS Scale is not predictive when PSYCHOSIS and /
    or SUBSTANCE ABUSE are present
  • Alcohol, drugs and severe mental illness may
    distort judgement such that the risk of suicide,
    intentional or otherwise, increases significantly

40
References
Glaezer, H. Clarkin, J.F. (Eds.), Depression
Behavioral and Directive Intervention Strategies.
New York Garland Press. Lalkhen, A. G ,
McCluskey, A. (2008) Clinical tests Sensitivity
and specificity. Continuing Education in
Anaesthesia, Critical Care and Pain 2008(8) p.
221-223. Available from http//ceaccp.oxfordjour
nals.org/content/8/6/221.full Accessed on
22-04-12. Meichenbaum, D. 35 Years of working
with suicidal patients Lessons learned.
Available from www.melissainstitute.org/documents
/35_Years_Suicidal_Patients.pdf Accessed on
21-04-12 Osman, A., Bagge, C. L., Gutierrez, P.
M., Konick, L. C., Kopper, B. A., Barrios, F.
X. (2001). The Suicidal Behaviors
Questionnaire-Revised (SBQ-R) Validation with
clinical and nonclinical samples. Assessment,
8(4), 443-454. Rudd, M.D., Berman, A.L., Joiner,
T.E., Nock, M.K., Silverman, M.M., Mandrusiak,
M., Orden, K., Witte, T. (2006). Warning signs
for suicide Theory, research, and clinical
applications. Suicide and Life Threatening
Behaviour, 36, 255-62. Samaritans information
sheet. Available from http//www.samaritans.org/
pdf/Samaritans-MentalHealthAndSuicide.pdf
Accessed on 21-04-12. Waraich, P., Goldner,
E.M., Somers, J.M. Hsu, L. (2004) Prevalence
and incidence studies of mood disorders A
systematic review of the literature. Canadian
Journal of Psychiatry 49(2), 124-138.
41
Thanks for Listening!
  • Questions?

42
Additional material
  • Additional information follows relevant to
    scoring the SBQ-R

43
Sensitivity
  • The sensitivity of a clinical test refers to its
    ability to correctly identify those with the
    disease
  • A test with 100 sensitivity correctly identifies
    all patients with the disease. A test with 80
    sensitivity detects 80 of patients with the
    disease (true positives) but 20 with the disease
    remain undetected (false negatives)

True positives
Sensitivity
False negatives
True positives

44
Specificity
  • The specificity of a test refers to its ability
    to correctly identify people without the disease
  • A test with 100 specificity correctly identifies
    all patients without the disease. A test with 80
    specificity correctly reports 80 of patients
    without the disease as test negative (true
    negatives) but 20 patients without the disease
    are incorrectly identified as test positive
    (false positives)

True negatives
Specificity
False positives
True negatives

45
Sensitivity and specificity
  • A test with a high sensitivity but low
    specificity results in many disease free
    patients being told they have the disease
  • Although the ideal (unrealistic) situation is for
    a 100 accurate test, a good alternative is to
    subject patients who are initially positive to a
    test with high sensitivity / low specificity to a
    second test with low sensitivity / high
    specificity
  • This way, nearly all the false positives can be
    correctly identified as disease negative

46
PPV and NPV
  • The Positive predictive value (PPV) of a test
    answers the question
  • How likely is it that this person has the
    disease
  • given that the test result is positive?
  • The Negative predictive value (NPV) of a test
    answers the question
  • How likely is it that this person does not have
    the disease
  • given that the test result is negative?

47
Receiver operator characteristics
  • Receiver operator characteristic curves are a
    plot of (1-specificity) of a test on the x-axis
    against its sensitivity on the y-axis for all
    cut-off values
  • An identical plot is produced when the false
    positive rate of a test is shown on the x-axis
    against the true positive rate on the y-axis
  • An ideal test is represented by the upper curve
    in the figure (C). The middle curve represents
    the characteristics of a test more typically seen
    in routine clinical use (B)
  • The area under this curve (AUC) represents the
    overall accuracy of a test, with a value
    approaching 1.0 indicating a high sensitivity and
    specificity
  • The dotted line on the graph (A) shows the
    line of zero discrimination with an AUC of 0.5
    (no better than tossing a coin)

48
Receiver operator characteristic curves
  1. Line of zero discrimination (AUC 0.5)
  2. Typical clinical test (AUC 0.5 1.0)
  3. Theoretically perfect test (AUC 1.0)

Lalkhen, A. G , McCluskey, A. Continuing
Education in Anaesthesia, Critical Care and Pain
2008(8) p. 221-223.
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