Rebecca Cowan, Suicide Risk Assessment

1. Dr. Rebecca Cowan
Eastern Virginia Medical School
Suicide Risk-Assessment in
Primary Care
4/1/2021
1

2. National Statistics
 One person dies by suicide every 16.6 minutes and
every year over 38,000 Americans die by suicide.
(CDC, 2010)
 Suicide is the 10th leading cause of death.
 There is one suicide attempt every 39 seconds and
750,000 – 1.2 million attempts each year.
 It is estimated that the cost of self-inflicted injuries and
suicide is over $34.6 billion per year.
 Over 90% of suicide victims have a significant
psychiatric illness or substance abuse disorder at the
time of their death.
4/1/2021
2

3. 4/1/2021
3

4. 4/1/2021
4

5. Suicide Counts and Rates by Year,
Virginia 2004-2008
700
750
800
850
900
950
2004 2005 2006 2007 2008
4/1/2021
5

6. 4/1/2021
6

7. Youth Suicide
 Third leading cause of death for ages 10 – 24.
 Second leading cause of death for American college
students.
 Everyday across the nation, there are approximately
12 youth suicides.
 Every 2 hours, 11 minutes, a person under the age of
25 dies by suicide in the United States.
 For every suicide by youth, it is estimated that 100-
200 attempts are made (YRBSS, 2003).
 Firearms are the most commonly used suicide
method accounting for 49% of suicide deaths.
4/1/2021
7

8. Females Ages 10-24
4/1/2021
8

9. Elderly Suicide
 Nationally, 15 older adults die each day by suicide.
 The number of males who commit suicide in late life is
five times that for women the same age.
 Eighty percent of seniors who die by suicide visited
their primary care physician within 30 days; 40% were
seen within the last week; and 20% saw their primary
care physician on the same day as the suicide.
4/1/2021
9

10. Worldwide
 500,000-1.2 million people die by committing
suicide each year worldwide.
 10-20 times more people attempt suicide
worldwide each year.
 In most countries, suicide is the leading cause of
death among people aged 15-34 years old.
4/1/2021
10

11. Biopsychosocial Model of Suicide
4/1/2021
11

12. Biopsychosocial Model of Suicide
Psychological
Processes
Biology
Environment
Events
How do you
think/feel about the
past, present, and
the future?
Mental Health
Disorder
Suicidal Behavior
4/1/2021
12

13. Neurobiological Basis of SI
 Suicidal behavior may be due to underlying
neurobiological factors.
 Serotonin depletion
 Higher concentration of norepinephrine.
4/1/2021
13

14. Genetics
• Relatives of people who have committed
suicide have about 10 times higher risk of
attempting suicide and an even greater
incidence of SI than controls.
• Twin studies
• Adoption studies
4/1/2021
14

15. Environment/Events
 Easy access to lethal means
 Local clusters of suicides that have a contagious
influence
 Job or financial loss
 Relational or social loss
4/1/2021
15

16. Sociocultural
 Lack of social support and sense of isolation
 Stigma associated with help-seeking behavior
 Barriers to accessing health care, especially mental
health and substance abuse treatment
 Certain cultural and religious beliefs
4/1/2021
16

17. Risk and Protective Factors
4/1/2021
17

18. Overall Risk Factors
Demographic male; widowed, divorced, single; increases with age; white
Psychosocial lack of social support; unemployment; drop in socio-
economic status; firearm access
Psychiatric psychiatric diagnosis; comorbidity
Physical Illness malignant neoplasms; HIV/AIDS; peptic ulcer disease;
hemodialysis; systemic lupus erthematosis; pain syndromes;
functional impairment; diseases of nervous system
Psychological
Dimensions
hopelessness; anxiety; psychological turmoil; decreased self-
esteem; narcissism & perfectionism
Behavioral
Dimensions
impulsivity; aggression; severe anxiety; panic attacks;
agitation; intoxication; prior suicide attempt
Childhood
Trauma
sexual/physical abuse; neglect; parental loss
Genetic & Familial family history of suicide, mental illness, or abuse
4/1/2021
18

19. Youth-Specific Risk Factors
 Loss or separation
 Harassment by peers (bullying)
 Gay, lesbian, bisexual or transgender sexual orientation
 Easy access to lethal methods, especially guns
 School crisis (disciplinary, academic)
 Feelings of isolation or being cut off from others
 Ineffective coping mechanisms
 Influence (either through personal contact or media representations) of
significant people who died by suicide
 Exposure to violence
 Family crisis (e.g., abuse, domestic violence, running away, child-parental
conflict)
 Unwanted pregnancy, abortion
 Infection with HIV or other STDs
4/1/2021
19

20. Psychiatric Illness and Suicide
 About 90% of people who commit suicide have a
known psychiatric illness such as:
 Major Depressive Disorder
 Schizophrenia
 Bipolar Disorder
 BPD & Sociopathic Personality Disorder
 Alcohol or other substance abuse
 Comorbidity of depressive-mood disorder and
substance abuse greatly increases the risk of
suicide.
4/1/2021
20

21. Suicide Rates in Specific Disorders
Condition %
Prior suicide attempt 27.5
Bipolar Disorder 15.5
Major Depression 14.6
Mixed drug abuse 14.7
Dysthymia 8.6
OCD 8.2
Panic Disorder 7.2
Schizophrenia 6.0
Personality Disorders 5.1
Alcohol Abuse 4.2
Cancer 1.3
General Population .72
4/1/2021
21

22. Comorbidity
 In general, the more diagnoses present, the higher the
risk of suicide.
 Psychological Autopsy of 229 Suicides (Henriksson et
al., 1993)
 44% had 2 or more Axis I diagnoses
 31% had Axis I and Axis II diagnoses
 50% had Axis I and at least one Axis III diagnosis
 Only 12 % had an Axis I diagnosis with no comorbidity
4/1/2021
22

23. Mood Disorders and Suicide
High-Risk Profile:
• Suicide occurs early in the course of illness
• Alcohol abuse
• First episode of suicidality
• Hospitalized for mood disorder secondary to
suicidality
• Risk for men is four times as high as for
women except in bipolar disorder where
women are equally at risk
4/1/2021
23

24. Schizophrenia and Suicide
High-Risk Profile:
• Previous suicide attempt(s)
• Significant depressive symptoms –
hopelessness
• Male gender
• First decade of illness – (however, rate
remains elevated throughout lifetime)
• Substance abuse
• Poor current work and social functioning
• Recent hospital discharge
4/1/2021
24

25. • Suicide occurs later in the course of the illness with
communications of suicidal intent lasting several years
• Men vs. Women
• Increased number of substances used, rather than the
type of substance appears to be important
• High Risk Profile:
• Recent or impending interpersonal loss
• Comorbid depression
Substance Abuse and Suicide
4/1/2021
25

26. Borderline Personality Disorder and
Suicide
Borderline Personality Disorder
 Lifetime rate of suicide - 8.5%
 With alcohol problems -19%
 With alcohol problems and major affective disorder -
38% (Stone 1993).
 Nearly 75% of patients with borderline personality
disorder have made at least one suicide attempt in their
lives.
4/1/2021
26

27. Culture and Suicide
 Increase in suicide rates for young African
Americans, particularly young males.
 High peaks of suicide in Pacific Islanders
 More frequent suicide attempts among Asian
females compared to females of other ethnic
groups
 Religion/Spirituality is associated with lower
SI/plan and with more negative attitudes towards
suicide.
4/1/2021
27

28. Gender and Suicide
 Men commit suicide 3 times more than women.
However, women attempt more than men.
 Suicide rates in women tend to peak around
middle age.
 Male suicide rates are much higher among the
elderly.
 Men choose more violent methods while women
usually choose self-poisoning.
 Single men have a higher rate of suicide risk than
single women.
 Divorce is a significant risk factor for men, but not
for women. 4/1/2021
28

29. Completer Profile
 Evenly distributed by SES, evenly distributed by
educated vs. uneducated, Western states
highest, 60% of firearms
 50% of completers were never in therapy
 75% of completers communicated thoughts about
their suicide aloud to several people months
before dying.
4/1/2021
29

30. Protective Factors
 What keeps you alive right now?
 What reasons do you have to live?
 Children and relationships with family and friends
are strong protective factors.
4/1/2021
30

31. Protective Factors
• Children in the home, except among those with
postpartum psychosis
• Pregnancy
• Deterrent religious beliefs
• Life satisfaction
• Positive coping skills
• Positive social support
• Positive therapeutic relationship
4/1/2021
31

32. Risk-Assessment
4/1/2021
32

33. IS PATH WARM?
 I-Ideation
 S-Substance Abuse
 P-Purposelessness
 A-Anxiety
 T-Trapped
 H-Hopelessness
 W-Withdrawal
 A-Anger
 R-Recklessness
 M-Mood Fluctuations
4/1/2021
33

34. Risk-Assessment
 Assessing suicide risk in primary care is complex.
 At the low end of the risk spectrum are patients
with thoughts of death or wanting to die, but
without suicidal thoughts, intent or a plan.
 Those with highly specific suicide plans,
preparatory acts or suicide rehearsals, and clearly
articulated intent are at the high end.
 There is no screening tool or questionnaire that
can accurately predict which patients from among
the many with suicidal risk will go on to make a
suicide attempt, either fatal or non‐fatal.
4/1/2021
34

35. 4/1/2021
35

36. Risk-Assessment
 Your task is not to “predict” suicide, but rather to
recognize when a patient has entered into a
heightened state of risk.
 It is important that you are able to differentiate
between various suicide related behaviors:
 Suicide threats
 Suicide plan
 Self-harm
 Suicide attempts with injuries
 Suicide attempts without injuries
4/1/2021
36

37. Risk-Assessment (Baseline)
 Baseline Risk- affected by predispositions to
suicidality and historical factors such as previous
suicidal behaviors.
 Static by nature and cannot be modified through
clinical intervention.
 Predispositions include:
 Genetic/Biological
 Historical factors
4/1/2021
37

38. Risk-Assessment (Acute)
 Acute Risk-the level of risk present during an
active suicidal crisis. Because these precipitating
risk factors are more dynamic in nature and
fluctuate over time, they are common targets for
clinical intervention.
 Precipitants and Stressors-Patients often choose to
kill themselves following an environmental event or
stressor. Identify the stressor and try to assist the
patient in resolving the problem.
 Symptomatic Presentation-Assess for Axis I and
Axis II disorders.
4/1/2021
38

39. Risk Assessment (Acute)
 Hopelessness-assess for presence, severity, and
duration of hopelessness.
 Nature of Suicidal Thinking-Assess frequency (How
often do you think about suicide?); Intensity (Could
you rate the intensity of your suicidal thoughts on a
scale of 0-10?); and Duration (How long do these
thoughts typically last?).
 Think about planning; availability of means;
preparatory behaviors; explicit intent, and deterrents
to suicide.
4/1/2021
39

40. Access to Lethal Means
 Always assess for availability of means.
 Suicide attempts almost always occur during
short-term peaks of distress.
 Among patients who survived life-threatening
suicide attempts, 24% made the decision within
five minutes preceding the attempts. 70% made
the decision within the preceding hour.
4/1/2021
40

41. • Suicide rates have been found to be highest immediately
following the purchase of a firearm, with declining risk as
time passes.
• 57 times higher during the first week following the
firearm purchase
• declining to 30 times higher during the 1st month
• 7 times higher after one year.
• Firearms account for 55-60% of suicides (Baker 1984, Sloan
1990).
• Firearms at home increase risk for adolescents.
• Risk management point: Inquire about firearms when
indicated and document instructions and response.
Risk-Assessment-Firearms
4/1/2021
41

42. Males Ages 45-64
4/1/2021
42

43. Females Ages 45-64
4/1/2021
43

44. Percentage of Suicides by Age
Group, Sex, and Mechanism
4/1/2021
44

45. Assessments
4/1/2021
45
 Beck Scale for Suicidal Ideation
 Beck Hopelessness Scale
 Beck Depression Inventory
 Suicidal Behaviors Questionnaire

46. Interventions
4/1/2021
46

47. Suicide & Primary Care
 Up to 88% of people who die by suicide had
contact with their primary care provider (PCP) in
the year prior to their death.
 Up to 66% had contact with their PCP in the
month prior to their suicide.
 These same individuals were more than twice as
likely to have seen their PCP as a mental health
professional in the year and month prior to their
suicide.
4/1/2021
47

48. Suicide & Primary Care
 From a liability risk standpoint, suicide claims are
considered to be low frequency/high severity.
 The overall number of suicide-related malpractice
cases is low; however, those that are filed tend to
result in higher than average insurance
payments.
 Physicians who actively address suicide risk, and
document their risk assessment and
recommended treatment plan, are far less likely
to be named in a lawsuit alleging improper care
resulting in suicide.
4/1/2021
48

49. Questioning Suicidal Patients
 A hierarchical approach is recommended:
 How have things been going for you recently?
 Can you tell me about anything in particular that has
been stressful for you?
 From what you have shared so far, it sounds like
you have been feeling depressed.
 It is not uncommon when depressed to feel that
things won’t improve and won’t get any better, do
you ever feel this way?
 People feeling depressed and hopeless sometimes
think about death and dying; do you ever have
thoughts about death and dying?
 Have you ever thought about killing yourself?
4/1/2021
49

50. Questioning Suicidal Patients
(ideation)
 Sample questions to assess suicidal ideation
 When did you begin having suicidal thoughts?
 Did any event (stressor) precipitate the suicidal
thoughts?
 How often do you have thoughts of suicide? How
long do they last? How strong are they?
 What is the worst they have ever been?
 What do you do when you have suicidal thoughts?
 What did you do when they were the strongest
ever?
4/1/2021
50

51. Questioning Suicidal Patients
(ideation)
 If your questioning reveals no evidence of suicidal
ideation, you may end the inquiry here and
document the finding.
 If your patient initially denies suicidal thoughts but
you have a high degree of suspicion or concern
due to agitation, anger, impaired judgment, etc.,
ask as many times as necessary in several ways.
 If your patient is having suicidal thoughts, ask
specifically about frequency, duration, and
intensity.
4/1/2021
51

52. Questioning Suicidal Patients (plan)
 Sample questions to assess suicidal planning:
 Do you have a plan or have you been planning to
end your life? If so, how would you do it? Where
would you do it?
 Do you have the (drugs, gun, rope) that you would
use? Where is it right now?
 Do you have a timeline in mind for ending your life?
Is there something (an event) that would trigger the
plan?
4/1/2021
52

53. Questioning Suicidal Patients (intent)
 Determine the extent to which the patient expects
to carry out the plan and believes the plan or act
to be lethal vs. self‐injurious.
 Also explore the patient’s reasons to die vs.
reasons to live. Inquire about aborted attempts,
rehearsals, and non‐suicidal self‐injurious actions,
as these are indicators of the patient’s intent to
act on the plan.
 Consider the patient’s judgment and level of
impulse control.
4/1/2021
53

54. Questioning Suicidal Patients (intent)
 Sample questions to assess intent:
 What would it accomplish if you were to end your life?
 Do you feel as if you’re a burden to others?
 How confident are you that this plan would actually end your
life?
 What have you done to begin to carry out the plan? For
instance, have you rehearsed what you would do (e.g., held
the pills or gun, tied the rope)?
 Have you made other preparations (e.g., updated life
insurance, made arrangements for pets)?
 What makes you feel better (e.g., contact with family, use of
substances?)
 What makes you feel worse (e.g., being alone, thinking about
a situation)?
 How likely do you think you are to carry out your plan?
 What stops you from killing yourself?
4/1/2021
54

55. Determine Treatment Plan
 Treatment
 Medication
 Benzodiazepines – may reduce risk by
treating anxiety
 Antidepressants
 Lithium, Anticonvulsants
 Antipsychotics
 Psychotherapeutic intervention
 Therapy
 Psychiatry
 Hospitalization
 Provide education to patient and family.
 Reassess for safety and suicide risk
frequently.
4/1/2021
55

56. Determine Treatment Plan
 For patients in the moderate and high risk categories and who
have symptoms of a psychiatric disorder, consider a referral to a
psychiatrist for a medication evaluation.
 For patients with alcohol or substance use issues, consider a
referral for alcohol/drug assessment and treatment.
 For patients in any risk category who are having significant
thoughts of death or suicide, consider a referral for individual or
family therapy.
 For all patients at increased risk, be sure to provide information
about the National Suicide Prevention Lifeline, 1‐800
273‐TALK (8255).
 For patients in the high risk group who are an imminent danger
to themselves, hospitalization is necessary. Patients can be
hospitalized voluntarily or involuntarily.
 Call Portsmouth Behavioral Health
 Call Virginia Beach Psychiatric Center
 Call the Police
4/1/2021
56

57. Suicide Contracts
 Problems:
• Commonly used, but no studies demonstrating ability to
reduce suicide.
• Not a legal document, whether signed or not.
 Possibilities:
• Useful when there is positive therapeutic relationship.
• If employed, outline terms in patient’s record.
• Rejection of contracts have significance.
4/1/2021
57

58. Managing Emotional Reactions
 Establishing a strong relationship with the suicidal
patient is imperative.
 A solid relationship is not just preferable, but
essential to successful work with suicidal patients.
 The patient’s goal to reduce psychological
suffering through suicide can come into direct
conflict with the physician’s goal to prevent death
by suicide.
 Resolution can be accomplished with a
straightforward common goal: To reduce the
patient’s suffering and emotional pain.
4/1/2021
58

59. Support Network
• Helping patients to identify and utilize a support
network is a key component of suicide
prevention.
• Having a predetermined list of supportive
individuals and their contact information will
increase the likelihood that the patient will seek
help before or during a crisis.
• Encouraging the patient to utilize their support
network even when they are not feeling suicidal
can help reduce the number of suicidal episodes
they experience.
4/1/2021
59

60. Resources
4/1/2021
60
 The National Suicide Prevention Lifeline (NSPL)
1-800-273-TALK (8255)
24-hour confidential crisis hotline
www.suicidepreventionlifeline.org
 Suicide Prevention Resource Center (SPRC)
www.sprc.org
 American Association of Suicidology (AAS)
www.Suicidology.org
 American Foundation for Suicide Prevention (AFSP)
www.afsp.org
 Prevent Suicide Virginia
www.preventsuicideva.org
 Virginia Department of Health Injury, Suicide and Violence Prevention Program
http://www.vahealth.org/Injury