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  • 1. Assessment of Suicide Risk
    • Dr David Harniess
  • 2. 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
  • 3. 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?
  • 4. 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]
  • 5. 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]
  • 6. 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]
  • 7. Map of Suicide Rates Globally http://www.who.int/mental_health/prevention/suicide/suicide_rates_chart/en/index.html [website accessed 24/1/2011]
  • 8. 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
  • 9.  
  • 10.  
  • 11. 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?
  • 12. 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
  • 13. 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
  • 14. 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
  • 15.
    • 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
  • 16.
    • 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
  • 17. BMJ Best Practice – Suicide Risk Assessment [www.bmj.com website accessed 24/1/11]
  • 18. 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
  • 19. Group Discussion
    • What questions would you use to assess serious intent of committing suicide?
    • What areas in your assessment should you cover?
  • 20. 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]
  • 21. 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?
  • 22. 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?
  • 23. Roleplay – a chance to practice
  • 24. 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.
  • 25.
    • 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
  • 26. 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)
  • 27.