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Important things to know
in working with
suicidal client
Michael McFarland, LMFT
Division of Behavioral Health
Where we are headed
 Frame the critical role of MH
 providers for suicide prevention
 Gain a glimpse of the prevalence
 Un...
Did you Know?
     Every year, over 33,000 people
     end their lives by suicide
     Between 30% and 50% of
     suicide...
Did you Know?
     Every year, over 33,000 people
     end their lives by suicide
     Between 30% and 50% of
     suicide...
Trends in Suicidal Behavior
      1990-1992 vs 2001-2003
National Comorbidity Survey Survey
Trends in Suicidal Behavior
      1990-1992 vs 2001-2003
National Comorbidity Survey Survey
Trends in Suicidal Behavior
      1990-1992 vs 2001-2003
National Comorbidity Survey Survey
What happens when we...
increase public awareness
broaden access to services
BUT don’t address TX
✓ Tx modalities and evid...
The Challenge
The assessment, management,
 and treatment of suicidality in
 clinical practice is one of the most
 challeng...
The Challenge
The assessment, management,
 and treatment of suicidality in
 clinical practice is one of the most
 challeng...
Prevalence:
How Big is the Problem?
Prevalence:
How Big is the Problem?
Prevalence:
How Big is the Problem?



1 million deaths by suicide worldwide
              every year
The Reality
>33,000 die annually by suicide in
the US
11th leading cause of death
2:1 suicide deaths to homicide deaths
KY...
Understanding Suicidality
Suicidality:
General Conceptual Considerations
Suicidality is time-limited
‣ suicide risk comes and goes
Episodes of risk ...
Suicidality:
 General Conceptual Considerations

Intent is variable, it comes and goes
  Variations in intent can occur ve...
Intent/Lethality as Related to Risk
            High   Low



  Intent




Lethality
Intent/Lethality as Related to Risk
            High   Low



  Intent




Lethality
Intent/Lethality as Related to Risk
            High   Low



  Intent




Lethality
Intent/Lethality as Related to Risk
            High   Low



  Intent




Lethality
Intent/Lethality as Related to Risk
            High   Low



  Intent




Lethality
Intent/Lethality as Related to Risk
            High   Low

                            Compounding
                      ...
SUICIDE: A MULTI-FACTORIAL EVENT
                            Psychiatric Illness
                              Co-morbidit...
SUICIDE: A MULTI-FACTORIAL EVENT
                            Psychiatric Illness
                              Co-morbidit...
Thomas Joiner: Interpersonal-
   Psychological Theory

           Developed Ability                                 Desire...
Thomas Joiner: Interpersonal-
   Psychological Theory

           Developed Ability                                 Desire...
Developed Capability
     Those who repeatedly attempt suicide emphasize how difficult it is...it is
   difficult to overc...
Developed Capability
        Those who repeatedly attempt suicide emphasize how difficult it is...it is
      difficult to...
1. Perceived Burdensomeness

2. Perceived Fail Belongingness




       Desire to die
1. Perceived Burdensomeness

2. Perceived Fail Belongingness



                   Hopelessness


       Desire to die
Perceived Burdensomeness
‣ Burdensomeness has to do w/ a
 person’s sense of self
‣ Defective; flawed to the point they
  pe...
FATAL misperception (cognitive distortions and
information processing---cognitive elements that feed the
suicidal mindset
...
Understanding The Suicidal Perspective
Can’t stop the pain

Can’t think clearly

Can’t make decisions

Can’t see any way o...
Understanding The Suicidal Perspective
Can’t stop the pain

Can’t think clearly

Can’t make decisions

Can’t see any way o...
Failed Belongingness
Fundamental human need for connection

So strong that if present it can be a preventative even
when o...
Tells Us What We Should be Exploring!
   Willingness to act (motivation to die)
    – What are your reasons for dying?

...
Practice Implications
Therapeutic Connection and
Collaboration are a Priority
 Research indicates one of the MOST
 important factors predicting ...
Therapeutic Connection and
Collaboration are a Priority
 Research indicates one of the MOST
 important factors predicting ...
Nature and response to suicidal
crisis
 Understand…               ALLIANCE             Response

   Suicidal thinking and ...
Make it a habit...ASK
 Ask EVERY client about past and
 current suicidality
 Periodically re-check with clients
 who have ...
Eliciting Suicidal Ideation: Use A
Hierarchical Approach
 Elicit
      past, present, and current suicidal thoughts,
  be...
ALWAYS BE SPECIFIC
   Specificity of questions improves assessment, reduces
    distress (use “kill yourself”, “suicide”)
...
Ask About Attempt Hx
 For previous attempts
 ➡ P =Precipitant
 ➡ N =Nature of attempt
 ➡ O =Outcome
 ➡ R =Response
• Disti...
The Most Critical Risk Factors:
What’s the Empirical Evidence?
 Anxiety/Agitation

  –Mental status impairment
 Sleep   ...
What effective treatments have in
common
Tend to be CBT based
Target suicidality directly
Provides client with understanda...
What effective treatments have in
common
Tend to be CBT based
Target suicidality directly
Provides client with understanda...
Case Conceptualization
 • It is vital that clients deconstruct their suicidal cycle—
   explore it, move into it.
 • Suppo...
Case Conceptualization
 • It is vital that clients deconstruct their suicidal cycle—
   explore it, move into it.
 • Suppo...
Safety Issues
Safety Issues
Safety Issues
                                non- harm
                     plan vs.
              safety
  1.  C risis  ...
Regarding “no harm”
contracts
 Not a legal document; cannot be used in
 the event of litigation
 Although commonly used, n...
Regarding “no harm”
contracts
 Not a legal document; cannot be used in
 the event of litigation
 Although commonly used, n...
Regarding “no harm”
contracts
 Not a legal document; cannot be used in
 the event of litigation
 Although commonly used, n...
Crisis safety plan
   Prioritized written list of coping strategies              See and
                                ...
Addressing access to lethal
means
 Access to certain highly lethal means
 is always one of the most important
 risk factor...
Addressing access to lethal
means
 Access to certain highly lethal means
 is always one of the most important
 risk factor...
Means Matter
Poisoning is involved in 74% of attempts, but has a
case fatality rate of 2%
Guns are involved in 5% of attem...
Social Worker Behaviors


              Respondents: 700 LCSW’s
              Questions concerning practice within last 2 ...
Social Worker Behaviors




Slovak, Karen, Briver, Thomas, W., Carlson, Karen. (2009). Client Firearm Assessment and Safet...
Factors affecting response
If endorsed not being adequately trained...
‣ Odds of routine firearm assessment decreased by 67...
Principles of Lethal Means Safety
Management
 Accessibility to lethal means is a treatment issue
 Inquire about guns at ho...
Discharge Planning, the
importance of follow up
connection
Post Discharge Heightened
Risk
 Heightened risk for suicidality has been
 broadly recognized across
  Differing countrie...
Potential Factors
Loss of immediate support system
Increased opportunity with access to
 means
Medication compliance
F...
Take Home Message
 Vast majority denied SI at D/C
 Nevertheless, the majority (re)
 experienced SI within the first 2 mon...
Connection impact among
pt’s refusing follow-up, Motto             &

 Refusing follow up care is widespread,
 11% to 50%...
Connection impact among
pt’s refusing follow-up, Motto                 &

 Refusing follow up care is widespread,
 11% to...
Motto et al, Results
Motto et al, Results
Motto et al, Results
Among the Contact Group
25% actually responded to the notes
“ I was surprised to get your letter. I
 thought that when a...
Among the Contact Group
25% actually responded to the notes
“ I was surprised to get your letter. I
 thought that when a...
Among the Contact Group
25% actually responded to the notes
“ I was surprised to get your letter. I
 thought that when a...
Among the Contact Group
25% actually responded to the notes
“ I was surprised to get your letter. I
 thought that when a...
Contact Information
In transition...



                   Michael McFarland
       michaelw.mcfarland@gmail.com
         ...
Important Things To Know
Important Things To Know
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Important Things To Know

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Basic information for working with someone who may be suicidal

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Important Things To Know

  1. 1. Important things to know in working with suicidal client Michael McFarland, LMFT Division of Behavioral Health
  2. 2. Where we are headed Frame the critical role of MH providers for suicide prevention Gain a glimpse of the prevalence Understand some core features of suicidality ✓ General conceptual considerations ✓ Basic model Consider some practice implications
  3. 3. Did you Know? Every year, over 33,000 people end their lives by suicide Between 30% and 50% of suicides in the United States occur in people who are receiving psychiatric treatment (Luoma, Martin, Pearson (2002); Lambert (2002)
  4. 4. Did you Know? Every year, over 33,000 people end their lives by suicide Between 30% and 50% of suicides in the United States occur in people who are receiving psychiatric treatment (Luoma, Martin, Pearson (2002); Lambert (2002)
  5. 5. Trends in Suicidal Behavior 1990-1992 vs 2001-2003 National Comorbidity Survey Survey
  6. 6. Trends in Suicidal Behavior 1990-1992 vs 2001-2003 National Comorbidity Survey Survey
  7. 7. Trends in Suicidal Behavior 1990-1992 vs 2001-2003 National Comorbidity Survey Survey
  8. 8. What happens when we... increase public awareness broaden access to services BUT don’t address TX ✓ Tx modalities and evidenced based protocols (What we do) ✓ Provider “know how” for engaging such clients (How we do it) ✓ Did you know the average clinician receives only about 2 hours of direct education around suicidality
  9. 9. The Challenge The assessment, management, and treatment of suicidality in clinical practice is one of the most challenging and stressful tasks for any clinicians. Helping our clients find a way to choose life is the most critical of all clinical endeavors.
  10. 10. The Challenge The assessment, management, and treatment of suicidality in clinical practice is one of the most challenging and stressful tasks for any clinicians. Helping our clients find a way to choose life is the most critical of all clinical endeavors.
  11. 11. Prevalence: How Big is the Problem?
  12. 12. Prevalence: How Big is the Problem?
  13. 13. Prevalence: How Big is the Problem? 1 million deaths by suicide worldwide every year
  14. 14. The Reality >33,000 die annually by suicide in the US 11th leading cause of death 2:1 suicide deaths to homicide deaths KY has the 12th highest rate of death by suicide in the nation 3:1 suicide deaths to homicide deaths 2nd leading cause of death in KY for those 15-34 yrs of age 4th leading cause of death in KY for those 35-54 yrs of age 65% of all suicide deaths in KY involve a firearm (2007)
  15. 15. Understanding Suicidality
  16. 16. Suicidality: General Conceptual Considerations Suicidality is time-limited ‣ suicide risk comes and goes Episodes of risk vary in severity and duration ‣ recovery trajectories vary across individuals, sometimes longer than we might guess Vulnerability for a new episode varies across individuals ‣ Variable configurations of predisposing risk factors ‣ Variable “thresholds” of activation
  17. 17. Suicidality: General Conceptual Considerations Intent is variable, it comes and goes Variations in intent can occur very quickly for some Intent is influenced by a complex web of factors Internal and external Ambivalence is almost always present Most motivations for death revolve around “putting an end to suffering”
  18. 18. Intent/Lethality as Related to Risk High Low Intent Lethality
  19. 19. Intent/Lethality as Related to Risk High Low Intent Lethality
  20. 20. Intent/Lethality as Related to Risk High Low Intent Lethality
  21. 21. Intent/Lethality as Related to Risk High Low Intent Lethality
  22. 22. Intent/Lethality as Related to Risk High Low Intent Lethality
  23. 23. Intent/Lethality as Related to Risk High Low Compounding Complexity Intent Subjective 1. how intently want to die 2. to what extent expects to die Objective 1. how likely from Lethality medical perspective
  24. 24. SUICIDE: A MULTI-FACTORIAL EVENT Psychiatric Illness Co-morbidity Personality Neurobiology Disorder/Traits Impulsiveness Substance Use/Abuse Hopelessness Severe Medical Suicide Illness Family History Access To Weapons Psychodynamics/ Psychological Vulnerability Life Stressors Suicidal Behavior
  25. 25. SUICIDE: A MULTI-FACTORIAL EVENT Psychiatric Illness Co-morbidity Personality Neurobiology Disorder/Traits Impulsiveness Substance Use/Abuse Hopelessness Severe Medical Suicide Illness Family History Access To Weapons Psychodynamics/ Psychological Vulnerability Life Stressors Suicidal Behavior
  26. 26. Thomas Joiner: Interpersonal- Psychological Theory Developed Ability Desire to die 1. Increased capability, overcome self- 2.“Perceived” burdensomeness preservation instinct through repeated 3. Failed belonging experience w/pain and provocation-- habituation Convergence Zone resulting in serious suicide attempt, or completion 44
  27. 27. Thomas Joiner: Interpersonal- Psychological Theory Developed Ability Desire to die 1. Increased capability, overcome self- 2.“Perceived” burdensomeness preservation instinct through repeated 3. Failed belonging experience w/pain and provocation-- habituation Convergence Zone resulting in serious suicide attempt, or completion 44
  28. 28. Developed Capability Those who repeatedly attempt suicide emphasize how difficult it is...it is difficult to overcome the most basic instinct of all; namely self-preservation. (Joiner, 2005) 45
  29. 29. Developed Capability Those who repeatedly attempt suicide emphasize how difficult it is...it is difficult to overcome the most basic instinct of all; namely self-preservation. (Joiner, 2005) ‣Accrues with repeated and escalating experiences involving pain and provocation, such as ‣ Past suicidal behavior, but not only that... ‣ Repeated injuries (e.g., childhood physical abuse); IV drug use ‣ Repeated witnessing of pain, violence, or injury (cf. physicians) ‣ Any repeated exposure to pain and provocation 45
  30. 30. 1. Perceived Burdensomeness 2. Perceived Fail Belongingness Desire to die
  31. 31. 1. Perceived Burdensomeness 2. Perceived Fail Belongingness Hopelessness Desire to die
  32. 32. Perceived Burdensomeness ‣ Burdensomeness has to do w/ a person’s sense of self ‣ Defective; flawed to the point they perceive themselves as a “burden” to others, the world, etc. therefore...
  33. 33. FATAL misperception (cognitive distortions and information processing---cognitive elements that feed the suicidal mindset Hopelessness tied to helplessness ‣ Opposing concept: self-efficacy/effectiveness
  34. 34. Understanding The Suicidal Perspective Can’t stop the pain Can’t think clearly Can’t make decisions Can’t see any way out Can’t sleep, eat or work Can’t get out of the depression Can’t make the sadness go away Can’t see the possibility of change Can’t see themselves as worthwhile Can’t get someone’s attention Can’t see to get control
  35. 35. Understanding The Suicidal Perspective Can’t stop the pain Can’t think clearly Can’t make decisions Can’t see any way out Can’t sleep, eat or work Can’t get out of the depression Can’t make the sadness go away Can’t see the possibility of change Can’t see themselves as worthwhile Can’t get someone’s attention Can’t see to get control
  36. 36. Failed Belongingness Fundamental human need for connection So strong that if present it can be a preventative even when other two factors are in place. Most usual precipitant for suicide is a broken relationship Motto... Therapeutic implications...
  37. 37. Tells Us What We Should be Exploring!  Willingness to act (motivation to die) – What are your reasons for dying?  Preparation to act (preparation and rehearsal behaviors) – Have you prepared for your death in any way?  Will, letters, finances, research? – Have you rehearsed your suicide?  Capability to act (previous suicidality, self-harm, trauma exposure) – Have you made a previous suicide attempt(s)? – Have you ever done things to harm or hurt yourself? – Have you ever experienced something you consider traumatic?  Barriers to act (reasons for living) – What are your reasons for living? – What keeps you alive, what keeps you going?
  38. 38. Practice Implications
  39. 39. Therapeutic Connection and Collaboration are a Priority Research indicates one of the MOST important factors predicting positive therapeutic outcome is the nature of the therapeutic relationship [carries more weight than model/ techniques]; (Norcross, Beutler & Levant, 2005; Siegel, 2010) Clinician characteristics... ✓ Presence ✓ Attunement Healing Relationship ✓ Resonance See, The Mindful Therapist, Daniel Siegel
  40. 40. Therapeutic Connection and Collaboration are a Priority Research indicates one of the MOST important factors predicting positive therapeutic outcome is the nature of the therapeutic relationship [carries more weight than model/ techniques]; (Norcross, Beutler & Levant, 2005; Siegel, 2010) Clinician characteristics... ✓ Presence ✓ Attunement Healing Relationship ✓ Resonance See, The Mindful Therapist, Daniel Siegel
  41. 41. Nature and response to suicidal crisis Understand… ALLIANCE Response Suicidal thinking and Validate depth of pain- behaviors makes sense Listen to client Maintain nonjudgmental/ Serves a functional supportive stance purpose Voice authentic concern Psychache View each client individually Keep focus on resolving pain; not simply controlling suicidal behavior.
  42. 42. Make it a habit...ASK Ask EVERY client about past and current suicidality Periodically re-check with clients who have previously denied Sullivan (2004) only 77% of clinical psychologists registered with the APA practice directorate reported performing suicidal ideation inquiries during the initial session with new patient
  43. 43. Eliciting Suicidal Ideation: Use A Hierarchical Approach  Elicit past, present, and current suicidal thoughts, behaviors, plans, intent  Sequence and word questions in effective manner to reduce anxiety, resistance and increase accuracy – First attempt, past several years (worst attempt---if multiple attempter), THEN current episode  Address client fears about “what will happen” if suicidal thoughts are acknowledged  Always thinking about……. – Severity (related to specificity) – Immediacy (Intent) – Volatility (impulsivity/self-control)
  44. 44. ALWAYS BE SPECIFIC  Specificity of questions improves assessment, reduces distress (use “kill yourself”, “suicide”) –No iatrogenic effect  Gould et al., Linehan et al.  Nature of Suicidal Thinking – Ideation: [FIDS] Frequency, Intensity/severity, Duration, Specificity (plans), availability/accessibility, active behaviors (preparation, rehearsal), intent (subj. vs. obj.), perceived lethality, degree of ambivalence, deterrents (family, religion, positive treatment relationship, support system) – Severity of psychological distress (Psychache)  Distress tolerance
  45. 45. Ask About Attempt Hx For previous attempts ➡ P =Precipitant ➡ N =Nature of attempt ➡ O =Outcome ➡ R =Response • Distinguish between chronic and acute ‣ Crisis threshold of activation  Multiple suicide attempters-more easily enter suicidal crisis from a broader array of triggers  Greater symptom severity: Anxiety, depression, hopelessness, anger, suicidal ideation (frequency, intensity, specificity, duration, intent) ‣ Crisis duration  Suicidal crisis for longer duration than SSA
  46. 46. The Most Critical Risk Factors: What’s the Empirical Evidence?  Anxiety/Agitation –Mental status impairment  Sleep Disturbance –Mental status impairment –Nightmares  Perceived Burdensomeness –Lack of social support (the most important protective factor)
  47. 47. What effective treatments have in common Tend to be CBT based Target suicidality directly Provides client with understandable model about suicidality Enhance skill deficit Provide crisis management Monitor treatment compliance Limit access to lethal means
  48. 48. What effective treatments have in common Tend to be CBT based Target suicidality directly Provides client with understandable model about suicidality Enhance skill deficit Provide crisis management Monitor treatment compliance Limit access to lethal means
  49. 49. Case Conceptualization • It is vital that clients deconstruct their suicidal cycle— explore it, move into it. • Support clients identifying components; recognizing patterns or themes associated with their cycle • Create a narrative of event • Construct a timeline Wenzel, Brown, Beck (2009). Cognitive Therapy for Suicidal Patients; Rudd, Joiner, & Rajab (2001). Treating Suicidal Behavior: An effective, time-limited approach
  50. 50. Case Conceptualization • It is vital that clients deconstruct their suicidal cycle— explore it, move into it. • Support clients identifying components; recognizing patterns or themes associated with their cycle • Create a narrative of event • Construct a timeline As long as suicidal clients are unable to understand their suicidal cycle, they remain victims to it. Wenzel, Brown, Beck (2009). Cognitive Therapy for Suicidal Patients; Rudd, Joiner, & Rajab (2001). Treating Suicidal Behavior: An effective, time-limited approach
  51. 51. Safety Issues
  52. 52. Safety Issues
  53. 53. Safety Issues non- harm plan vs. safety 1. C risis eans ontra ct f leth al m c eme nt o Ma nag 2. plan ning 3 . DC
  54. 54. Regarding “no harm” contracts Not a legal document; cannot be used in the event of litigation Although commonly used, no studies have shown their effectiveness in reducing suicides Suicide prevention contracts are only as reliable as the state of the therapeutic alliance. Therefore, use in ED settings or with newly admitted and unknown inpatients is not recommended.
  55. 55. Regarding “no harm” contracts Not a legal document; cannot be used in the event of litigation Although commonly used, no studies have shown their effectiveness in reducing suicides Suicide prevention contracts are only as reliable as the state of the therapeutic alliance. Therefore, use in ED settings or with newly admitted and unknown inpatients is not recommended. Who said this?
  56. 56. Regarding “no harm” contracts Not a legal document; cannot be used in the event of litigation Although commonly used, no studies have shown their effectiveness in reducing suicides Suicide prevention contracts are only as reliable as the state of the therapeutic alliance. Therefore, use in ED settings or with newly admitted and unknown inpatients is not recommended. Who said this?
  57. 57. Crisis safety plan  Prioritized written list of coping strategies See and handouts resources for use during a suicidal crisis.  Uses a brief, easy-to-read format that uses the patients’ own words.  Development and implementation of a safety plan IS treatment  Should be the first intervention with a suicidal patient  Helps to immediately enhance client’s sense of control over suicidal urges and thoughts and conveys a feeling that they can “survive” suicidal feelings  Enhances coping skills  Provides concrete steps to guide client during crisis  Enlist’s client’s collaboration
  58. 58. Addressing access to lethal means Access to certain highly lethal means is always one of the most important risk factors to consider Research indicates addressing this issues is often absent in conversations between client and provider Critical risk management issue & treatment issue
  59. 59. Addressing access to lethal means Access to certain highly lethal means is always one of the most important risk factors to consider Research indicates addressing this issues is often absent in conversations between client and provider Critical risk management issue & treatment issue
  60. 60. Means Matter Poisoning is involved in 74% of attempts, but has a case fatality rate of 2% Guns are involved in 5% of attempts, but have a case fatality rate of 91% When a gun is used in an attempt 85% of the time it results in fatality Firearm factors... ‣ Inherently lethal ‣ Immediacy ‣ Irreversibility ‣ Most other means provide opportunity for “backing out”--even hangings; about half of the hangings deaths are partial suspension
  61. 61. Social Worker Behaviors Respondents: 700 LCSW’s Questions concerning practice within last 2 years... 1. “I routinely assess if my clients own a gun and have access to guns.” 2. “I routinely counsel my clients about firearm safety.” Slovak, Karen, Briver, Thomas, W., Carlson, Karen. (2009). Client Firearm Assessment and Safety Counseling: The Role of Social Workers. Social Work.
  62. 62. Social Worker Behaviors Slovak, Karen, Briver, Thomas, W., Carlson, Karen. (2009). Client Firearm Assessment and Safety Counseling: The Role of Social Workers. Social Work.
  63. 63. Factors affecting response If endorsed not being adequately trained... ‣ Odds of routine firearm assessment decreased by 67% ‣ Odds of safety counseling occurring decreased by 86% If reported not being aware of risks associated with with firearms in the home... ‣ Odds of routine firearm assessment decreased by 60.3% ‣ Odds of safety counseling occurring decreased by 52.9%
  64. 64. Principles of Lethal Means Safety Management Accessibility to lethal means is a treatment issue Inquire about guns at home or outside the home (car, office, etc.); intention to purchase a gun Explain the elevated risk Adopt common MI stance; think about the stages of change Designate a willing, responsible person to remove and safely secure guns & ammunition outside home and unknown to client; secure medications Have direct phone contact w/ designated person for confirmation; DOCUMENT
  65. 65. Discharge Planning, the importance of follow up connection
  66. 66. Post Discharge Heightened Risk  Heightened risk for suicidality has been broadly recognized across  Differing countries  Differing populations  Differing time periods  Estimated 6% of all suicides occur in the immediate post discharge period (Troister et al, 2008)  41% of suicides among those received psychiatric care can occur within 1 year of d/c.  Additional clustering within 1st month/ esp. 1st wk is also evident (Pirkola et al, 2005)
  67. 67. Potential Factors Loss of immediate support system Increased opportunity with access to means Medication compliance Follow up compliance Questionable stability at D/C Lack of change in social stressors— basic life conditions remain unchanged
  68. 68. Take Home Message  Vast majority denied SI at D/C  Nevertheless, the majority (re) experienced SI within the first 2 months of d/c to outpt tx.  Pt. d/c with ongoing depressive symptomatology appear to be a increased risk for SI+ as well as subsequent rehospitalization
  69. 69. Connection impact among pt’s refusing follow-up, Motto &  Refusing follow up care is widespread, 11% to 50% reported in numerous studies  1969-1974, total of 3,005 in nine inpat. Psych CT=30 days D/DT ≠ 30 Died w/n 30 of D/C TG NFTG Undetermined Ltr. 1 per month for 4 months (4) 1 every 2 months forNCG CG 8 months (4) 1 every 3 months for 4 yrs (16) total 5 yrs and 23 contacts
  70. 70. Connection impact among pt’s refusing follow-up, Motto &  Refusing follow up care is widespread, 11% to 50% reported in numerous studies “Dear___________:  1969-1974, total oftime since you It has been some 3,005 in nine inpat. Psych a the hospital, and D/C CT=30 days D/DT ≠ 30 were here Died w/n 30 of we hope tings are going well for you. TG NFTG Undetermined If you wish to drop us a note we Ltr. would be glad to here from you.” 1 per month for 4 months (4) 1 every 2 months forNCG CG 8 months (4) 1 every 3 months for 4 yrs (16) total 5 yrs and 23 contacts
  71. 71. Motto et al, Results
  72. 72. Motto et al, Results
  73. 73. Motto et al, Results
  74. 74. Among the Contact Group 25% actually responded to the notes “ I was surprised to get your letter. I thought that when a patient left the hospital your concern ended there.” “You are the most persistent son of a bitch I’ve ever encountered, so you must really be sincere in your interest in me.”
  75. 75. Among the Contact Group 25% actually responded to the notes “ I was surprised to get your letter. I thought that when a patient left the hospital your concern ended there.” “You are the most persistent son of a bitch I’ve ever encountered, so you must really be sincere in your interest in me.”
  76. 76. Among the Contact Group 25% actually responded to the notes “ I was surprised to get your letter. I thought that when a patient left the hospital your concern ended there.”
  77. 77. Among the Contact Group 25% actually responded to the notes “ I was surprised to get your letter. I thought that when a patient left the hospital your concern ended there.” “You are the most persistent son of a bitch I’ve ever encountered, so you must really be sincere in your interest in me.”
  78. 78. Contact Information In transition... Michael McFarland michaelw.mcfarland@gmail.com 502.544.7663

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