Essentials of Suicide Risk Assessment and Intervention: Part II

Transcription

1 Essentials of Suicide Risk Assessment and Intervention: Part II Joseph H. Obegi PsyD AGENDA REVIEW SAFETY PLANNING MEANS RESTRICTION TREATMENT LIABILTY 10 minutes 60 minutes 60 minutes 30 minutes 20 minutes CLINICAL MANAGEMENT Ongoing Monitoring Regularly assessing progress and suicide risk level so that treatment can be adapted as necessary Treatment Intervening to instill hope, address the drivers of suicidal behavior, and teach more adaptive coping skills MONITOR TREAT ASSESS ASSURE Suicide Risk Assessment Collecting clinical information to estimate the degree of suicide risk and devise an plan that reduces risk Safety Management Apply interventions that address the patient s immediate or near-term safety. 3

2 WHY MEANS MATTER Attempt with less Fewer deaths by lethal means suicide Suicidal persons Lethal means not available Delay in attempt Suicidal urges pass Effective help Fewer suicide attempts Adapted from CDC (1992) 4 METHODS OF SUICIDE Fatal Attempts Nonfatal Attempts 2.2% 1.8% Cutting/ Piercing 3.7% Other 0.8% Firearm 0.7% Suffocation 0.6% Fall Fall 16.5% Poisoning 25.2% Suffocation 50.7% Firearm 21.1% Other 21.9% Cutting/ Piercing 54.9% Poisoning Methods of Self-Harm: 2004 Guns are not the most common means of suicide attempt, but they result in more deaths than every other method combined. Self-injury by firearm was the most lethal method with an 85% fatality rate. Suffocation was the next most lethal method (69% fatality rate). Cutting and poisoning, which includes drug overdoses, infrequently lead to death. 87% of firearm suicides are by men and 44% of adolescent suicides involve a firearm. Harvard Injury Control Research Center (2012) 5 FIREARMS AND SUICIDE 8 7 Firearm Suicide 6 Rate per 100K Firearm Homicide Year Firearm-Related Death Rates The rate of firearm homicide has declined steadily while firearm suicide rate has begun rising, increasing roughly 14 percent between 2006 and Together these trends keep the overall gun death rate the same (Brady Campaign, 2016). Adapted from Brady Campaign (2016); Wintemute (2015) 6

3 FIREARMS AND SUICIDE All suicide Firearm suicide 25 Rate per 100K % Adults living with a firearm in the home Firearm Suicides: Ownership, Urbanization, and Age The rate of suicide by firearm rises as the percentage of adults owning a firearm in a state is larger. Having a firearm in the home raises the risk of suicide by about 3 times (Anglemyer et al., 2014). Risk is higher if the the firearm is kept loaded or unlocked (Kellerman et al., 1992). The rate of suicide also increases as the area becomes more rural and people age. Adapted from Miller et al. (2012) 7 FIREARMS AND SUICIDE Cut Drowning Fall Firearm Poisoning Suffocation Rate per 100K Large central Large fringe Medium Small Micropolitan NonCore metro metro metro metro Extent of Urbanization Firearm Suicides: Ownership, Urbanization, and Age The rate of suicide by firearm rises as the percentage of adults owning a firearm in a state is larger. Having a firearm in the home raises the risk of suicide by about 3 times (Anglemyer et al., 2014). Risk is higher if the the firearm is kept loaded or unlocked (Kellerman et al., 1992). The rate of suicide also increases as the area becomes more rural and people age. Adapted from Miller et al. (2012) 8 FIREARMS AND SUICIDE Firearm homicides Firearm suicides 14 Rate per 100K Age group (yrs) Firearm Suicides: Ownership, Urbanization, and Age The rate of suicide by firearm rises as the percentage of adults owning a firearm in a state is larger. Having a firearm in the home raises the risk of suicide by about 3 times (Anglemyer et al., 2014). Risk is higher if the the firearm is kept loaded or unlocked (Kellerman et al., 1992). The rate of suicide also increases as the area becomes more rural and people age. Adapted from Wintemute (2015) 9

4 MEANS SAFETY Why Restricting Access is Critical Many suicides are impulsive Suicidal crises are time limited Most attempt survivors do not go on to die by suicide Smith, Jones, & Doe (2017) 10 MEANS SAFETY Myth: They will find a way 74% of people believe that all or most jumpers would have found another way to die However, means substitution does generally not occur Betz et al. (2013); Miller et al. (2006) 11 MEANS SAFETY Rates per 100K Male Total Co Year Female Total Co Year Carbon Monoxide Suicides in England As natural gas replaced coal gas and cleaner oil-based gases became more common in England and Wales, the percentage of carbon monooxide (Co) dropped from 10% in 1964 to a small fraction of 1% in During this period the overall suicide rate decreased by more than 30%. Adapted from Kreitman (1976) 12

5 MEANS SAFETY Most lethal pesticides banned Rate per 100K Poisoning Hanging Other Year Poisoning Suicides in Sri Lanka The proportion of suicides due to pesticide poisoning increased from 37% in 1959 to 72% Suicides by poison fell dramatically after the most lethal pesticides were banned in 1995 and1998. There was not corresponding shift in suicide methods. Adapted from Gunnell et al. (2007) 13 MEANS SAFETY No Yes 10 Rate per 100K National rate: Waiting period Background check Open carry restricted Gun lock required Firearm Suicides and State Handgun Legislation States that makes handguns more difficult to obtain have substantially lower rates of firearm suicide (Anestis & Anestis (2005). Moreover, states that repeal laws regulating firearms, see an immediate and lasting increase in firearm suicides (Anestis & Anestis, 2015; Crifasi et al., 2015). Adapted from Anestis & Anestis (2015) 14 MEANS SAFETY Percentage of parents restricting access or disposing Untrained parents Trained parents Prescribed Over-the-counter Alcohol Firearms medication medication Parent Education and Restricting Access When hospital staff provided injury education prevention to parents making an emergency mental health visit for their children, parents were 3.6 times more likely to limit access to lethal means than were parents who did not receive education. Adapted from Kruesi et al. (1999) 15

6 TALKING ABOUT MEANS 1. Ask about firearms 2. Inform about risks 3. Explore options 4. Enlist supportive others 5. Confirm JOSEPH H. OBEGI Adapted from Bryan et al. (2011) 16 TALKING ABOUT MEANS Ask about Firearms Is there a gun in the home or any other place? How many? Where and how are the guns and ammunition stored? What is the purpose of the firearm? Do you intend to purchase a gun? Bryan et al., (2011); Simon (2007) 17 TALKING ABOUT MEANS Inform about Risks A suicidal person with access to a gun is 7x more likely to plan to die with a gun A gun in the home raises the risk of suicide by 3x Most adolescent suicides are by firearm Risk is higher when guns are loaded or unlocked 85% of suicides with a gun are fatal Betz et al. (2011); Brent (2001); Vyrostek et al. (2004) 18

7 TALKING TO GUN OWNERS Not anti-gun but anti-suicide Not gun control but gun safety Respect gun rights Emphasize that removal is temporary Present a menu of options Bryan et al. (2011) 19 MEANS SAFETY Options: Storage* Use gun safes and trigger locks Store unloaded Store and lock ammunition separately Key or combination kept with supportive other or in a bank s safe deposit box Dismantle firearm and give a critical piece to a supportive other Bryan et al. (2011); Kruesi et al (1995) 20 MEANS SAFETY Options: Removal Temporarily held by supportive other outside the home (not hidden in the home) Temporarily held by local law enforcement Dealers and shooting ranges may rent storage Bryan et al. (2011); Kruesi et al (1995) 21

8 MEANS SAFETY Options: Disposal Sell the firearm (but interim safety steps are still need) Disposal by local law enforcement* Bryan et al. (2011); Kruesi et al (1995) 22 MEANS SAFETY Confirm the Restriction From the supportive other not the gun owner Verbal or written (means receipt); no texting Bryan et al. (2011) 23 MEANS SAFETY Returning the Firearm Reassessment of suicide risk completed Crisis has passed Meaningful reduction in emotional distress Absence of warning signs Bryan et al. (2011) 24

9 SUICIDAL THINKING AND BEHAVIOR IN THE USA STB in 2014 In 2014, 9.4 million adults aged 18 or older thought seriously about suicide in the past 12 months, including 2.7 million who made suicide plans and 1.1 million who made a nonfatal attempt (3.9%, 1.1% and.5%, respectively). 2.7 Million Made suicide plans 9.4 Million Adults had serious thoughts of dying by suicide.9 Million Made plans and attempted suicide.2 Million Made no plans and attempted suicide Lipari et al. (2015) 25 SUICIDAL THINKING IN THE USA Of high schoolers 17% had serious SI in the past 12 months Of adults with MDD 30% had SI in the past 12 months Of all attempts 60% occur in the 1st year after onset of SI ASFP based on 2016 data 26 CONTRACTS ARE LEGALLY SUSPECT Instigated by fear of liability Do not protect against legal liability Can be a source of liability Not legally binding Garvey et al. (2006), Simon (2004) 27

10 CONTRACTS ARE CLINICALLY DUBIOUS No indications for use, standards, or training May result in false confidence about patient safety Tends to be used as a stand-alone intervention Power likely dependent on strength of alliance Overlooks the suicidal mind Garvey et al. (2006), Simon (2004) 30

11 CONTRACTS CAN BE MISUNDERSTOOD May lead the patient to feeling coerced May interfere with open communication May lead to perception of pro forma care Competence of suicidal patients is suspect Garvey et al. (2006), Simon (2004) 31 CONTRACTS HAVE NO RESEARCH BASIS May lead the patient to feeling coerced May interfere with open communication May lead to perception of pro forma care Competence of suicidal patients is suspect Garvey et al. (2006), Simon (2004) 32

12 INTRODUCE THE PLAN Do the thinking now During your last crisis, what was your thinking like? In times of trouble, you may not see that you have options other than harming yourself Sit side-by-side Stanley & Brown (2008), SAMHSA (2015) 34 WARNING SIGNS Recognize when you re in a crisis How will you know when the safety plan should be used? Thoughts, feelings, behaviors, images, sensations Recorded in the patients own words Stanley & Brown (2008), SAMHSA (2015) 35 COPING STRATEGIES Do what works What can you do, on your own, if you become suicidal again, to help yourself not to act on your thoughts? How likely do you think you would be able to do this step during a time of crisis? Have you learned anything from previous suicide attempts that might be helpful in keeping you safe for now? Stanley & Brown (2008) 36

13 PEOPLE AND PLACES Find distractions Who or what social settings help you take your mind off your problems at least for a little while? Who helps you feel better when you socialize with them? Stanley & Brown (2008) 37 FAMILY AND FRIENDS Turn to others for support Among your family or friends, who do you think you could contact for help during a crisis? Who is supportive of you and who do you feel that you can talk with when you re under stress? Stanley & Brown (2008) 38 HELPERS AND AGENCIES Seek professional help Who are the mental health professionals that we should identify to be on your safety plan? Are there other health care providers? TALK (8255) Stanley & Brown (2008) 39

14 REMOVE MEANS Means matter What items are you most likely to use to harm yourself? How can you safely remove them for the time being? Who can you call to come and get them? Stanley & Brown (2008) 40 REASONS FOR LIVING Instill hope What are the things most important to you? What are some reasons you have to live? Administer the Reasons for Living Scale (Linehan et al., 1983) Make reminders of hope more available SAMHSA (2015) 41 ADDITIONAL TIPS Share the plan with trusted others Keep multiple copies Update the plan Review daily and practice the plan Document the plan Use a smartphone app like MY3 Matarazzo et al. (2014), SAMHSA (2015) 42

15 SAFETY PLANNING: RESEARCH FINDINGS Bryan et al. (2017) Compared to contracts, less negative emotionally, increased hope, admission was less likely Miller et al. (2017) One year post ED visit, fewer suicide attempts vs. TAU Zonana et al. (2017) 6 months post safety plan, fewer ED visits and hospitalizations 43 STEPPED CARE FOR SUICIDALITY IPT with Suicide-Specific Tx Partial Hospitalization Emergency Respite Care Suicide-Specific OPT B-Intervention + Follow-Up Hotlines Adapted from Jobes (2016) 44 HOSPITALIZATION & SUICIDE 70 Post-Discharge Suicides In a study in England and Wales, 24% of all postdischarge suicides occurred in the first 3 months. Of those, 45% occurred in the first month. The highest number of suicides occurred in the first week with many occurring on the first day. A meta-analysis found no factors to be strongly associated with post-discharge suicide (Large et al., 2011). In fact, many suicides occurred among patients categorized as low risk. Number of suicides per week % of suicides occurred in the first 3 months post-discharge Weeks post-discharge Appleby et al. (1999) 45

16 HOSPITALIZATION & SUICIDE 70 Cumulative Probability of Suicide per Population Depressive disorder cohort Bipolar disorder cohort Schizophrenia cohort Other mental disorders cohort Substance use disorder cohort Nonmental disorders cohort Time Since Hospital Discharge, days Post-Discharge Suicides by Mental Disorder Olson et al. (2014) conducted a longitudinal, retrospective study of inpatients aged 18 to 64 years in the Medicaid program. During the first 90 days after hospital discharge, the cumulative risk for suicide was significantly greater for each of the 5 mental disorder cohorts than for the nonmental disorder cohort. Risk was highest for depressive and bipolar disorders. Adapted from Olson et al. (2016) 46 APPROACHES TO TREATMENT Reevaluate the current treatment plan Optimize the treatment of the cooccurring conditions Initiate suicide-focused psychotherapy Modify/Optimize pharmacotherapy Ward-Ciesielski & Linehan, (2014) 47 APPROACHES TO TREATMENT: MEDICATION Effective medications for mental disorders are not uniformly effective for SIB Lithium Five-fold reduced risks of suicide and attempts in bipolar spectrum, MDD Clozapine Five-fold reduced risk of attempts in schizophrenia patients, has unique FDA approval SSRIs Decreases ideation but not attempts Baldessarini & Tondo (2011) 48

17 FEATURES OF SUICIDE-SPECIFIC TREATMENTS Therapeutic alliance Informed consent/commitment to tx Secure safety Target what the patient believes is driving risk Monitor and treat until suicidality is resolved Regularly reassess risk Consult 49 EXAMPLE OF INFORMED CONSENT Let s begin our discussion about suicide with something plain: you can of course kill yourself, and in the grand scheme of things there is remarkably little I or anyone else can do about it. To be frank, it is your life and ultimately up to you whether you choose to live it. However, from a clinical standpoint, we have a dilemma because state laws and the clinical standard of care require me to not permit you to take your life if you pose a clear and imminent danger to yourself. This duty can create a serious strain between your personal autonomy and my professional obligation, which could mean that I might have to commit you to an inpatient hospital setting, even against your will. While I do not want any of my patients to die by suicide, I nevertheless understand that for some people there is no other way to cope with their situation. From Jobes (2016) 50 EXAMPLE OF INFORMED CONSENT By the end of the day on average 100-plus Americans will die by their own hand, and about 30% of them will be in concurrent mental health care. I therefore have no illusions that mental health care will necessarily save your life. That said, I would rather not debate with you whether you can kill yourself; instead I would propose an evidence-based treatment designed to save your life. The research shows that most suicidal people respond to this treatment within 3 months. So why not give it a try? You have everything to gain and really nothing to lose. You can of course kill yourself later, when you are no longer in treatment. It is your life to live or not as you see fit. But then, what is the hurry? One day we all die. Finally, if suicide is the best way to do to deal with your situation, then what are you doing here with me? Perhaps it is not yet your time to die? From Jobes (2016) 51

18 APPROACHES TO TREATMENT: DBT Overview Designed for BPD, one target is SB CBT and Eastern concepts Long-term treatment: skills training group and weekly one-to-one sessions Emotional regulation, interpersonal effectiveness, distress tolerance, and mindfulness 52 APPROACHES TO TREATMENT: DBT Research 4 RCTs As much as 50% fewer suicide attempts, NSSI Longer times to attempt Fewer ER visits, hospitalizations Gains preserved 1 year post-treatment 53 APPROACHES TO TREATMENT: CBT-SP Overview 10 sessions Phase 1: Consent, SRA, safety plan, formulation, treatment goals Phase 2: Skill acquisition, cognitive restructuring, RFLs Phase 3: Consolidation, relapse prevention 54

19 Brown et al. (2005) 55 APPROACHES TO TREATMENT: CBT-SP Research 1 RCT, 120 ER suicide attempters 18-month follow-up 50% less likely to reattempt, fewer suicides Decreases in hopelessness, depression, but not SI APPROACHES TO TREATMENT: CAMS Overview Suicidality-specific treatment Qualitative assessment Targets patient-identified drivers Framework, theoretically agnostic Generally, short-term 56 APPROACHES TO TREATMENT: CAMS Research 2 RCTs (one feasibility trial, one full trial) Decreases in SI, most change in first 1-2 months Gains preserved at 12 month follow-up Comtois et al. (2011); Jobes et al. (2017) 57

20 58 APPROACHES TO TREATMENT: ASSIP Overview Video-based intervention Short-term Session 1: Narrative interview Session 2: Review of video Session 3: Shared case formulation and safety strategies APPROACHES TO TREATMENT: ASSIP Research 1 RCT, 120 suicide attempters 24-month follow-up period 83% reduced risk of attempts vs. TAU 72% fewer days in the hospital Gysin-Maillart et al. (2016) 59 SUICIDE AND LIABILITY There are about 44,000 suicides each year Of these 90% likely had a mental health condition In the month before 19% had contact with a mental health provider Of psychologists 1 in 5 will have a patient suicide in their career ASFP ; Cho et al. (2016); Luoma et al. (2002); Chemtob et al. (1989) 60

21 SUICIDE AND LIABILITY The APA Trust says 6 th most common claim The APA Trust says 2 nd most costly claim Of claims against psychiatrists 17% are for suicide According to TJC Poor SRA is the most common root cause Bongar & Sullivan (2013); Simon (2006); Joint Commission (2016) 61 NEGLIGENCE Right to be free of unwanted injury Negligence infringes on this right Negligence = failure to use reasonable care Professional negligence = failure to use reasonable care in rendering services California Evidence Code 62 NEGLIGENCE Damage Duty Deviation Direct Damage or harm to the patient Doctor-patient relationship exists Deviation from the standard of care Deviation was the direct cause of damage Simon (2006) 63

22 LEGAL DUTY TO PREVENT SUICIDE If those who are caring for and treating mentally disturbed patients know of facts from which they could reasonably conclude that the patient would be likely to self-inflict harm in the absence of preventative measures, then those caretakers must use reasonable care under the circumstances to prevent that harm from occurring. West s California Jurisprudence 3D 64 AN SRA ESTABLISHES REASONABLE CARE Systematic collection data Estimated suicide risk Informs a plan to mitigate risk Documentation is evidence of reasonable care Obegi (2017) 65 CONTACT ME Joseph H. Obegi PsyD Address 2055 Anderson Road Davis, CA Phone & jhobegi@gmail.com Web JOSEPH H. OBEGI