Assessment of Suicide Risk <ul><li>Dr David Harniess </li></ul><ul><li>MBChB MRCGP DCH DRCOG </li></ul>
Learning Objectives <ul><li>Rationale for importance of suicide risk assessment </li></ul><ul><li>Identifying people at hi...
Discussion in pairs <ul><li>Why do you think assessing for suicide risk is important? </li></ul><ul><li>Do you think GPs c...
Incidence and prevalence  of suicide worldwide <ul><li>Globally 1.4% cause of global burden of disease </li></ul><ul><li>I...
Current trends <ul><li>In the last 45 years suicide rates have increased by 60% worldwide.  </li></ul><ul><li>Suicide is a...
WHO Statistics  Distribution of suicide rates globally (per 100 000) by gender and age, 2000 http://www.who.int/mental_hea...
Map of Suicide Rates Globally http://www.who.int/mental_health/prevention/suicide/suicide_rates_chart/en/index.html  [webs...
Changes in Incidence of Suicide over recent decades in Australia Harrison, J. et al Youth Suicide and Self-Injury Australi...
 
 
Small Group Discussion <ul><li>What do you think are the risk factors for increased risk of completing suicide? </li></ul>...
Risk factors for completing suicide <ul><li>Demographic  Social  </li></ul><ul><li>Older age  Social isolation </li></ul><...
Beck’s Scoring system <ul><li>Objective Circumstances Related to Suicide Attempt   </li></ul><ul><li>Isolation </li></ul><...
Beck’s Scoring System <ul><li>Final acts in anticipation of death (will, gifts, insurance)  </li></ul><ul><ul><li>0  None ...
<ul><li>Self Report   </li></ul><ul><li>Alleged purpose of attempt </li></ul><ul><ul><li>0 To manipulate environment, get ...
<ul><li>Attitude toward living/dying </li></ul><ul><ul><li>0 Did not want to die </li></ul></ul><ul><ul><li>1 Components o...
BMJ Best Practice – Suicide Risk Assessment [www.bmj.com website accessed 24/1/11]
Some Comments on  Assessment Tools <ul><li>Only a tool – may get in way of doctor-patient rapport and consultation </li></...
Group Discussion <ul><li>What questions would you use to assess serious intent of committing suicide? </li></ul><ul><li>Wh...
Suicide risk assessment  has 4 steps: <ul><li>Assessment of the 5 components of suicide: ideation, intent, plan, access to...
Asking about suicidal ideation – some example questions <ul><li>Have you thought that your life is not worth living? </li>...
Asking about suicidal intent and plans – some example questions <ul><li>How do you feel when you start thinking about taki...
Roleplay – a chance to practice
Some Tips - Do’s and Don’ts <ul><li>DO’s </li></ul><ul><li>Establish rapport. </li></ul><ul><li>Use a calm, patient, non-j...
<ul><li>Approx 75% of completed suicides the individual had seen a doctor within the prior year before their death  (45%-6...
Resources available <ul><li>WHO mhGAP Intervention Guide (www.who.int) </li></ul><ul><li>SUPRE publications on WHO website...
<ul><li>THANKS FOR LISTENING </li></ul><ul><li>ANY QUESTIONS? </li></ul>
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Harniess 02

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

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