Disclosures 8/28/2014 4:40 AM 1

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1 Charles Hart Enzer, MD, FAACAP Child -Adolescent -Adult -Family Psychiatry 5599 Kugler Mill Road Cincinnati, OH WebSite: TinyURL.com/EnzerMD Disclosures Volunteer Associate Professor of Psychiatry University of Cincinnati Medical Center July, 1987 to 2014 Senior Attending Good Samaritan Hospital Department of Psychiatry 2002 to Present Suicide Assessment In Less than 45 Seconds Learn about Our Reluctance to Assess Effectively Learn the Research behind Effective Assessment Learn How to Assess Suicidality in Less Than 45 Seconds Slide 1 No Potential Conflicts of Interest to Report. Practiced Psychiatry for about 90,000 Hours. While Being My Patient, None Have: Attempted Suicide Committed Suicide Among These Patients: Four Handed Me Knives Two Handed Me Straight-Edged Barber s Razors One Handed Me a Heavy Glass Ashtray One Handed Me a Revolver One Submitted to the Police a Uzi Submachine Gun Slide 2 Inpatient Suicide is A Traumatic Event Often Difficult to Predict A Relatively Rare Occurrence Suicide is the Eleventh Leading Cause Of Death in the United States Approximately 1,500 Suicides Occur in Inpatient Hospital Units in the United States Each Year [41] Patient Suicide in The Hospital Is One Of The Most Frequently Reported Occurrences Reported To The Joint Commission Percentage of Hospital Patients Who Self-Harm Including Suicide Attempts andsuicide -- Come From the Psychiatric Units? % 2. 75% 3. 50% 4. 25% From 1995 to 2005, Suicide Was The Most Common Sentinel Event [28] Slide 3 Slide 4 8/28/2014 4:40 AM 1

2 Percentage of Good Sam Patients Who Self- Harm Including Suicide Attempts and Suicide -- Come From the Psychiatric Units? % 2. 75% 3. 50% 4. 25% Which of These is a Psychiatric Diagnosis: A. Agitation/Agitated B. Anxious C. Depressed/Depression D. Paranoid E. Suicidal/Suicide 1. A and B 2. D 3. C and D 4. None of the Above 5. All of the Above Slide 5 Slide 6 Suicides in the Medical/Surgery Settings Do Occur Suicides Pose Profound Challenges for Patients Suicides Pose Profound Challenges for Their Families Suicides Pose Profound Challenges for Health Care Workers Suicides Pose Profound Challenges for Hospital Administrators [3] Joint Commission s Sentinel Alert In 1998, on Preventing Inpatient Suicides. To Assure That Patients Outside of Psychiatric Units are Appropriately Screened and Managed [1] About Half of Inpatient Suicides and Suicide Attempts Occur While the Patient Is Not on an Inpatient Psychiatry Unit [32], [26] At Trihealth, about Half Intentionally Self-Harming Were Not from the Department of Psychiatry. [27] Slide 7 Slide 8 8/28/2014 4:40 AM 2

3 Risk Factors for Suicide Factors Contributing to Patients Killing Themselves While Admitted to General Hospital Medical/Surgical Units Have Not Been Well Described Agitation and Impulsiveness Increase the Risk of Imminent Suicide Slide 9 Risk Factors Which May be Absent among Medical/Surgery Patients Past History of Psychiatric Illness, Substance Abuse Suicidality Suicide Attempts Present Depression Known Mental Disorder [18] Slide 10 People Who Are Suicidal May Have: Risk Factors: Depressive Disorders Psychotic Disorders Substance Abuse Anxiety Disorders 20% of Subjects with Panic Disorder 12% of Those with Panic Attacks Personality Disorders Organic Disorders No Mental Disorder [40], [21] Slide 11 Risk Factors are More Stable Risk Factors are Distal in Their Relationship to Suicidal Behavior Slide 12 8/28/2014 4:40 AM 3

4 Most Suicide Risk Factors Have Very Little Clinical Relevance: Risk Factors range Over 1 Year to More Than 20 Years Clinicians are Worried about Decisions Over: o The Next Few Days o The Next Few Hours o The Next Few Minutes o Not Years Slide 13 Warning Signs for Potential Suicidal Behavior are Far More Useful: Immediately Observable Implicate Current Functioning Warning Signs Help to Answer the Critical Questions: o What is My Patient Doing (Observable Signs) o What is My Patient Saying (Expressed Symptoms) Slide 14 Warning Signs Elevate the Risk of Dying by Suicide to: The Next Few Days? The Next Few Hours The Next Few Minutes [5] We Can Educate One Another We Can Help Those in Need We Can Make a Difference Divide Up into Teams of 4 Each Team to Have One of these: 2 Different Professions 2 Different Levels of Training Slide 15 Slide 16 8/28/2014 4:40 AM 4

5 Warning Signs Suggesting Suicide Imminent????? Slide 17 Warning Signs Suggesting Increased Desperation and Imminent Risk: [1] Agitation Complaining of Unrelenting Pain Crying Spells Refusing Medications Decreased Emotional Reactivity Impulsivity Increased Anxiety or Panic Irritability Slide 18 More Warning Signs Suggesting Increased Desperation and Imminent Risk: [1] Refusing Visitors Requesting Early Discharge Decreased Interest in Prognosis Decreased Interest in Treatment Feelings of Worthlessness Helplessness Hopelessness Suicidal General Hospital Patients Unlike Psychiatric Inpatients: [11] Attempt Suicide after Admission More Rapidly Attempt Suicide after Admission with little Threats Attempt Suicide after Admission with little Warnings Refusing to Eat Slide 19 Slide 20 8/28/2014 4:40 AM 5

6 Suicide Prevention on Medical/Surgical Units Should Emphasize: [33] Focusing on Behavioral Warning Signs of Imminent Danger: o Agitation o Irritability Patient Assessment Slide 21 To Prevent Suicide in the Med/Surg Environment [6] Appreciate the Potential Lethality of Acute Psychic and Motoric Agitation Rather than Surveillance of Agitated Patients Calm Them with: Soothing Lighting Soothing Music Soothing Aroma o Soothing Massage Secure Their Surroundings Psychiatric Nursing Consultation Slide 22 These Patients Need Regular Assessment: [24] Patients Recovering from A Suicide Attempt Patients with Delirium or Dementia When Either Agitated or Impulsive Patients Overwhelmed by Their Illness or Disability Slide 23 The Relationship Between Suicide & Mental Illnesses Is Confusing: [18] Medication Can Reduce Depressive Symptoms without Reducing Suicidality Only Lithium Has Evidence for Reducing Suicidality Suicide Is an Adverse Effect of about 200 Medications Psychotherapy Can Reduce Suicide Without Changing Affective Symptoms Over 95% of Those with Mental Disorders Do Not Complete Suicide Slide 24 8/28/2014 4:40 AM 6

7 Name a Suicide Predictor????? Research Shows so-called No-Suicide Contracts are Not Effective [14] Slide 25 Slide 26 Suicide Predictors Ranked: [15] Reasons Clinicians Reluctant to Evaluate for Suicidality????? 1. Depressive Disorders are the Least Predictive 2. Suicidal Ideation is a Better Predictor Than Depressive Disorders 3. Hopelessness is the Strongest Predictor Slide 27 Slide 28 8/28/2014 4:40 AM 7

8 We are Reluctant to Evaluate for Suicidality: Fear/Anxiety about Addressing Death Anxiety of Getting Close to Dying Patients I Will Become Emotionally too Close Reluctance to Talk Openly Enquiry Will Unleash Uncontrollable Emotions Discussing Patients Concerns is of No Benefit to Patients Death/Depression Is Inevitable/Untreatable Discussing Patient Concerns is of No Benefit Professionally or to Our Role as Givers of Care Slide 29 How to Screen for Suicidality???? Slide 30 False Suicidality Myths????? Slide 31 False Suicide Myths Discussing Suicide Gives the Patients Ideas [16] Patients Who Repeatedly Make Suicide Threats Don t Really Want to Die [17] A History of Prior Attempts Means That the Patient Is Not Serious [18] Depression Is A Normal Reaction to Medical Illness Wanting to Die Is Common In the Seriously Ill Patient [19], [20] Suicidality and Depression Will Simply Fade Away with Time Slide 32 8/28/2014 4:40 AM 8

9 Ask about Suicidality Directly: [21] The Most Effective Method of Uncovering Thoughts of Self-Harm Just as Important for Givers of Care to Be Able to Ask about Suicide As to Query Other Discomforting Topics Sexual History Substance Abuse Domestic Violence The Importance of Learning This Skill 1. Recency Suicide Assessment in less than 45 Seconds 2. Aggravating Social Pressure 3. Tug towards Life 4. Immediacy Cannot be Overstated Slide 33 Slide 34 Evidenced Based Questions and Procedures: High Sensitivity True Positive Rate High False Negative Rate Low High Specificity True Negative Rate High False Positive Rate Low Assessment for Suicidality: Must Be Focused Must Be Clinically Relevant Must Be Evidence Based Must Be Acceptable to the Busy Clinician Slide 35 Slide 36 8/28/2014 4:40 AM 9

10 Questions Evaluated to Detect a Suicide Plan [22] Thoughts of Death 100% Sensitive 81% Specific in Discovering Suicidality Feeling Suicidal 83% Sensitive 98% Specific Do You Wish That You Were Dead? 92% Sensitive 93% Specific Slide 37 Indirect Questions Make it Easier to Say Everything General Principles of Effective Interviewing: Avoid Asking Direct Questions Indirect Questions Ease Talking about Sensitive Matters Universalize Many People..... People Who Have Name the Disorder/Complaint..... Use a Time Reference I Wonder When was the First Time You..... I Wonder When was the Last Time You..... Slide Assess Recency of Suicidal Urges People with [Disease/Complaint] from Time to Time, Think about Suicide I Wonder When Was the Last Time You Thought "I'd be Better off out of the Picture, Dead about Suicide" 2. If Suicidal Ideation Recent -- Assess Aggravating Social Pressure to Suicide I Wonder, Who Else Would be Better Off With You Out of the Picture, Dead Slide 39 Slide 40 8/28/2014 4:40 AM 10

11 3. If Suicidal Ideation Recent -- Assess Tasks that ResistSuicide I Wonder What Are Your Reasons -- if any -- That You Have Decided to LiveTODAY Only Tasks, or Unfinished Business, or Obligations -- Count None of these are Tasks: o o o Moral Reasons Philosophical Reasons Religious Reasons Slide If Suicidal Ideation Recent -- Assess Immediacy of Suicide I Wonder How Much Time Do We Have before You Kill Yourself? A year? A month? A week? A day? An hour? Minutes? Slide 42 What is the Key Procedure to Prevent Self-harm and Suicide????? What is the Key Procedure to Prevent Self-harm and Suicide??? 1. Enter answer text... Slide 43 Slide 44 8/28/2014 4:40 AM 11

12 Doctoring Is An Artful Skill: Boundless in Its Potential Providing Suicide Risk Assessment to All Patients Another Step in Realizing Our Potential Key to Our Being Experienced as Providing Quality Care: Being Curious Being Thorough Enjoying the Patient Enjoying Providing Care Slide 45 Slide Goodies Click on: "Prescribing Is So Easy, Understanding People So Hard." PowerPoint Presentation Print Handout of All Slides Print Handout of Just Slides with Notes Citations and Sources Consulted Slide 47 Kafka, Franz. (1917) A Country Doctor. The Penal Colony, Stories and Short Pieces (translated by W. & E. Muir, 1961), p New York: Shocken Books. Slide 48 8/28/2014 4:40 AM 12