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Harniess 02
 

Harniess 02

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    Harniess 02 Harniess 02 Presentation Transcript

    • Assessment of Suicide Risk
      • Dr David Harniess
      • MBChB MRCGP DCH DRCOG
    • Learning Objectives
      • Rationale for importance of suicide risk assessment
      • Identifying people at high risk of suicide
      • Considering assessment tools
      • Considering questioning techniques and practice in roleplay
    • Discussion in pairs
      • Why do you think assessing for suicide risk is important?
      • Do you think GPs can make a difference in reducing suicide in society?
      • What has been your experience so far in assessing suicide risk?
    • Incidence and prevalence of suicide worldwide
      • Globally 1.4% cause of global burden of disease
      • In 2001 the yearly global toll from suicide exceeded the number of deaths by homicide (500 000) and war (230 000).
      • Highest rates are found in Eastern Europe and the lowest are found mostly in Latin America, in Muslim countries and in a few of the Asian countries.
      • There is little information on suicide from African countries. No data found on Libya
      [WHO Press release 2010 - website accessed 23/1/2011 http://www.who.int/mediacentre/news/releases/2004/pr61/en]
    • Current trends
      • In the last 45 years suicide rates have increased by 60% worldwide.
      • Suicide is among the three leading causes of death among those aged 15-44 years in some countries, and the second leading cause of death in the 10-24 years age group
      • Rates among young people have been increasing to such an extent that they are now the group at highest risk in a third of countries, in both developed and developing countries.
      Suicide prevention (SUPRE) SUPRE Report [www.who.int website accessed on 23/1/11]
    • WHO Statistics Distribution of suicide rates globally (per 100 000) by gender and age, 2000 http://www.who.int/mental_health/prevention/suicide/suicide_rates_chart/en/index.html [website accessed 24/1/2011]
    • Map of Suicide Rates Globally http://www.who.int/mental_health/prevention/suicide/suicide_rates_chart/en/index.html [website accessed 24/1/2011]
    • Changes in Incidence of Suicide over recent decades in Australia Harrison, J. et al Youth Suicide and Self-Injury Australia Research Centre for Injury Studies Flinders Univeristy Adelaide
    •  
    •  
    • Small Group Discussion
      • What do you think are the risk factors for increased risk of completing suicide?
      • Are you aware of any screening tools to assess risk of suicide?
    • Risk factors for completing suicide
      • Demographic Social
      • Older age Social isolation
      • Male Unemployment
      • Clinical Co-morbidity
      • Depressed mood state
      • Previous suicidal attempt/self harm Substance misuse Serious intent Physical illness
      • Hopelessness/wish to die Psychiatric disorder(i.e. anxiety
      • Anxiety symptoms disorder, schizophrenia)
      • History of depressive disorder
      • Family history
      • Other
      • Access to means of suicide (weapons, drugs etc )
      Palazidou, E. WONCA Working Party on Mental Health Workshop – Suicide risk
    • Beck’s Scoring system
      • Objective Circumstances Related to Suicide Attempt
      • Isolation
        • 0 Somebody present
        • 1 Somebody nearby, or in visual or vocal contact
        • 2 No one nearby or in visual or vocal contact
      • Timing
        • 0 Intervention is probable
        • 1 Intervention is not likely
        • 2 Intervention is highly unlikely
      • Precautions against discovery/intervention
        • 0 No precautions
        • 1 Passive precautions (as avoiding other but doing nothing to prevent their intervention; alone in room with unlocked door)
        • 2 Active precautions (as locked door)
      • Acting to get help during/after attempt
        • 0 Notified potential helper regarding attempt
        • 1 Contacted but did not specifically notify potential helper regarding attempt
        • 2 Did not contact or notify potential helper
    • Beck’s Scoring System
      • Final acts in anticipation of death (will, gifts, insurance)
        • 0 None
        • 1 Thought about or made some arrangements
        • 2 Made definite plans or completed arrangements
      • Active preparation for attempt
        • 0 None
        • 1 Minimal to moderate
        • 2 Extensive
      • Suicide Note
        • 0 Absence of note
        • 1 Note written, but torn up; note thought about
        • 2 Presence of note
      • Overt communication of intent before the attempt
        • 0 None
        • 1 Equivocal communication
        • 2 Unequivocal communication
      • Self Report
      • Alleged purpose of attempt
        • 0 To manipulate environment, get attention, get revenge
        • 1 Components of above and below
        • 2 To escape, surcease, solve problems
      • Expectations of fatality
        • 0 Thought that death was unlikely
        • 1 Thought that death was possible but not probable
        • 2 Thought that death was probable or certain
      • Conception of method's lethality
        • 0 Did less to self than s/he thought would be lethal
        • 1 Wasn't sure if what s/he did would be lethal
        • 2 Equaled or exceeded what s/he thought would be lethal
      • Seriousness of attempt
        • 0 Did no seriously attempt to end life
        • 1 Uncertain about seriousness to end life
        • 2 Seriously attempted to end life
      Beck’s Scoring System
      • Attitude toward living/dying
        • 0 Did not want to die
        • 1 Components of above and below
        • 2 Wanted to die
      • Conception of medical rescuability
        • 0 Thought that death would be unlikely if he received medical attention
        • 1 Was uncertain whether death could be averted by medical attention
        • 2 Was certain of death even if he received medical attention
      • Degree of premeditation
        • 0 None; impulsive
        • 1 Suicide contemplated for three hours of less prior to attempt
        • 2 Suicide contemplated for more than three hours prior to attempt
      • 15-19 Low Intent 20-28 Medium Intent 29+ High Intent
      • There is also a greater risk of repeated attempts the higher the intent rating.
      Beck’s Scoring system
    • BMJ Best Practice – Suicide Risk Assessment [www.bmj.com website accessed 24/1/11]
    • Some Comments on Assessment Tools
      • Only a tool – may get in way of doctor-patient rapport and consultation
      • Another factor not listed is chosen method of attempted death e.g. hangings & firearms vs poisoning
      • Essential to collect information on the patient's psychiatric history (90% of people who commit suicide have a psychiatric diagnosis)
      • Low validity at predicting who actually commits suicide – not substitute for clinician’s judgement
      • High false positives
    • Group Discussion
      • What questions would you use to assess serious intent of committing suicide?
      • What areas in your assessment should you cover?
    • Suicide risk assessment has 4 steps:
      • Assessment of the 5 components of suicide: ideation, intent, plan, access to lethal means, and history of past suicide attempts
      • Evaluation of suicide risk factors
      • Evaluation of current experience (what's going on?)
      • Identification of targets for intervention.
      BMJ Best Practice – Suicide Risk Assessment [www.bmj.com website accessed 24/1/11]
    • Asking about suicidal ideation – some example questions
      • Have you thought that your life is not worth living?
      • Have you thought about ending your life?
      • Do you feel that your reasons for living outweigh your reasons for dying?
      • If you had a way, would you try to take your own life?
      • If you thought you were going to die, would you take steps to save yourself?
      • How often do you think about dying?
        • How long does it usually take for the thoughts to go away?
      • Are thoughts about dying or taking your life overpowering to you?
    • Asking about suicidal intent and plans – some example questions
      • How do you feel when you start thinking about taking your own life?
      • Have you ever thought of ways to take your own life?
      • Have you ever had specific thoughts or plans about taking your own life?
        • Have you set a time or place?
        • What are those plans?
      • Do you have access to (method) (e.g., pills, poisons, medication, weapon)?
        • Do you think you could get (method) if you needed to?
      • Do you think you would die if you used (method)?
      • Have you done anything or taken steps to prepare to take your own life (e.g., writing suicide note or will, arranging method, giving away possessions)?
      • Do you think that you could take your own life?
      • Do you feel ready to die?
    • Roleplay – a chance to practice
    • Some Tips - Do’s and Don’ts
      • DO’s
      • Establish rapport.
      • Use a calm, patient, non-judgmental, and empathic approach.
      • Begin with supportive statements and open-ended inquiries.
      • Start with open move towards more specific questions in a sensitive and non-judgmental way that creates an opportunity for dialogue;
      • Do ask specific questions about self-harm, suicidal thoughts, plans, attitudes towards suicide, history of suicidal behaviour, thoughts of death, and feelings of hopelessness.
      • DON’TS
      • Allow your personal feelings and reactions to influence assessment and treatment.
      • Rush the patient or ask leading questions.
      • Interrogate the patient or force the patient to defend his or her actions.
      • Minimise the patient's distress.
      • Undermine the seriousness of the suicidal thought or action.
      • Approx 75% of completed suicides the individual had seen a doctor within the prior year before their death (45%-66% within the prior month)
      • Empathy and listening
      • Non- judgemental approach
      • Identifying and treating any underlying psychiatric condition
      • Support and ensuring patient safety
      • Consider patient leaflets in waiting areas
      You can make a difference
    • Resources available
      • WHO mhGAP Intervention Guide (www.who.int)
      • SUPRE publications on WHO website `Preventing suicide: a resource for GPs’
      • BMJ Best Practice - Assessing Suicide Risk (www.bmj.com)
      • THANKS FOR LISTENING
      • ANY QUESTIONS?