Evaluation and Management of Suicidality in Individuals with Substance Use Disorders

Transcription

1 The heart and science of medicine. UVMHealth.org/MedCenter Evaluation and Management of Suicidality in Individuals with Substance Use Disorders Understanding the person beneath the diagnosis Sanchit Maruti, MD, MS Medical Director and Attending Psychiatrist University of Vermont Medical Center Addiction Treatment Program Burlington, Vermont

2 Disclosures Name American Academy of Addiction Psychiatry National Institute of Mental Health (NIMH) New Hampshire Medical Society Providers Clinical Support System For Medication Assisted Treatment (PCSS-MAT) University of Vermont Frymoyer Scholar State of Vermont Blueprint of Health Vermont EPSCoR Relevant Financial Relationships: For What Role Consultant for Revision of Buprenorphine Waiver Course Co-Investigator: Small Business Innovation Research Grant (SBIR) Phase I, R43 MH : Evaluating the Comparative Validity and Reliability of SERAS: A Decision Support Tool for Assessing Near Term Risk of Suicide in Emergency Departments Buprenorphine Waiver Course Clinical Expert Co-Investigator: Medication Assisted Treatment (MAT) Integration into a Primary Care Internal Medicine Residency: A Novel Interprofessional Addiction Treatment Curriculum Principle Investigator: Medication Assisted Treatment Program Learning Sessions Co-Investigator: SBIR Phase 0 Grant: Modeling of Addiction Experts Cognitive Process in Assessing Near Term Suicide Relevant Financial Relationships: What was Received Honorarium Grant-Support Honorarium Honorarium Grant-Support Grant-Support Grant-Support

3 Outline Objectives Epidemiology Process Clinical Management Summary

4 Objectives Describe major risk factors for suicidal ideation Describe Screening methods for evaluating suicidal ideation List key elements of safety planning for patients with suicidal ideation

5 Outline Objectives Epidemiology Process Clinical Management Summary

6 Epidemiology: General ~44,000 Americans die by Suicide every year Men are 4x more likely to complete suicide 50% fire arms; ~27% suffocation; 16% poisoning Veterans comprise 22% of suicides Suicide Attempts: 1.1 Million per year Women are 3x more likely to attempt suicide Over 494,169 people with self-inflicted injuries were treated in U.S. emergency departments in Suicides result in over $51 billion in combined medical and work loss costs per year. AFSP, 2017 CDC, 2013 CDC, 2014

7 7 CDC, 2014

8 Rates of Suicide CDC, 2014

9 Prevalence Suicidal Ideation Life-Time Suicidal Ideation Past -Year Suicidal Attempts Life-Time Suicidal Attempts Past -Year Adults 13.5% 3.1% 4.6% 0.5% Youth 16% (13% with Plan) 7.8% Borges et al., 2006 Eaton et al., 2012 Kessler et al., 1999

10 5 1 Suicides Hour

11 Co-Occurring Conditions NSDUH, 2016

12 Risk Factors Adults Previous suicide attempt(s) History of depression or other mental illness Alcohol or Substance Use Disorder Family history of suicide or violence Significant Changes Feeling alone Adolescents Previous suicide attempt(s) History of depression or other mental illness (especially Psychosis) Alcohol or Substance Use Disorder Family history of suicide or violence Significant Changes (agitation, intoxication, recent stressful life event) Feeling alone (living outside home) Chronic Pain or Physical illness Difficulty with school/work Bullying LGBTQ History of physical or sexual Abuse History of aggression, impulsivity, severe anger Pathologic Internet Use Nonsuicidal self-injury (NSSI) Shain, 2016

13 Addiction and Suicide ~40% of patients seeking treatment for SUDs report a history of suicide attempts SUDs increase the chance of dying by suicide by suicide 5-15 fold Roy 2007, 2009, 2010 Wilcox et al., 2004

14 Increasing Prevalence Rates in Adults Non-Medical Prescription Opioid Use [NMPOU] Use: : 12-month: 1.8%; Lifetime:4.7% : 12-month: 4.1%; Lifetime: 11.3% Individuals Ever receiving Treatment 5.5% with NMPOU 17.7 with NMPOU-Disorder Alcohol: From to : Alcohol use increasing from 65.4% to 72.7%, High-risk drinking increasing from 9.7% to 12.6%, DSM-IV Alcohol Use Disorder increasing from 8.5% to 12.7% APA, 2013 Grant et al., 2017 Saha et al., 2016

15 Joint Commission Requirements Detecting and treating suicide ideation in all settings: Hospitals, Ambulatory Care, Behavioral Health, Home Care, Nursing Care Centers, Office-Based Surgery National Patient Safety Goals (NPSG ) Elements of Performance (EP): EP 1: Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide. EP 2: Address the patient s immediate safety needs and most appropriate setting for treatment. EP 3: When a patient at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as a crisis hotline) to the patient and their family. Ambulatory Care Provision of Care (PC), Treatment, and Services: PC : The organization has a process that addresses the patient s need for continuing care, treatment, or services after discharge or transfer. Joint Commission, 2016

16 Zero Suicide in Health and Behavioral Care Suicide deaths for individuals under care within health and behavioral health systems are preventable Supported by: 2012 National Strategy for Suicide Prevention National Action Alliance for Suicide Prevention (Action Alliance) Education Development Center's Suicide Prevention Resource Center (SPRC) Substance Abuse and Mental Health Services Administration (SAMHSA)

17 Outline Objectives Epidemiology Process Clinical Management Summary

18 Continuum of Suicidal Behavior Suicidal Ideation to Suicide Attempt 16% within 12 months 32% during lifetime Suicidal Plan to Suicide Attempt 32% within 12 months 54% during lifetime Suicide Attempters 16% will make a second suicide attempt within 12 months Death from suicide: 2-13% in subsequent years Beghi et al., 2010 Borges et al., 2006 Nock et al., 2008

19 Increased Probability of Eventual Death by Suicide Individuals with SUDs are many more times more likely to: Think about suicide Attempt suicide Die by suicide Planning Attempts Completions Thoughts Youdelis-Flores and Ries, 2015

20 Models of Suicide Ideation Shneidman Pain (Psychache) Press (Stress) Pertubation (Agitation) Beck Wish to Live Wishe to Die Brown, 2005 Shneidman, 1998

21 Contributing Factors Neurobiology Depressant Effects Impaired Decision Making Increased SI Worsening Psychosocial Effects Shame Despair Impulsivity

22 Imaging of Addiction Martinez et al., 2012 Schmidt et al., 2014

23 Outline Objectives Epidemiology Process Clinical Management Summary

24 Clinical Evaluation Screen all patients for suicide ideation Current State Past History Chronological Assessment of Suicidal Events (CASE) Family History Review screening questionnaires before the patient leaves the appointment or is discharged. Joint Commission, 2016 Shea, 2011

25 Questions Passive SI With all these challenges, do you sometimes feel you would be better off dead? Active SI Recent Have you thought about killing yourself? Current Are you feeling suicidal right now? Do you have a plan? Plans What are some ways that you have considered? Access to means Firearms, Pills, Rope? Preparations Note, Changes to will/insurance, Giving away belongings?

26 Screening: Patient Health Questionnaire (PHQ-9) Overview Screening, diagnosing, monitoring and measuring severity of depression Rapid completion and scoring Incorporates DSM-IV criteria Assigns weigh to the degree to which depressive problems affect patient s level of function Psychometric Properties Diagnostic validity established in Primary care and Obstetric Clinics Sensitivity and Specificity of 88% for Major Depression (Score >10)

27 Acronyms SAD PERSONS Sex Age Depression Previous Attempt Ethanol Abuse Rational Thinking Loss Social Supports Lacking Organized Plan No Spouse Sickness IS PATH WARM Ideation Substance Abuse Purposelessness Anger Trapped Hopelessness Withdrawing Anxiety Recklessness Mood Change Rudd et al., 2006

28 Safety Planning High Risk Maintain one-to-one constant observation. Ensure safe health care environment Provide immediate access to care (911, Emergency Services) Moderate Risk make personal and direct referrals to outpatient behavioral health and other providers for follow-up care within one week of initial assessment. All Patients with SI Provide the number to local crisis and peer support contact and the National Suicide Prevention Lifeline, TALK (8255), Conduct safety planning by collaboratively identifying possible coping strategies with the patient. Restrict access to lethal means. Joint Commission, 2016

29 Collaborative Assessment and Management of Suicidality (CAMS) Emphasizes collaboration and empathy Enhances the therapeutic alliance and increase treatment motivation in the suicidal patient Uses the Suicide Status Form (SSF) Evidence based Jobes, 2012

30 Preventing Addiction Related Suicide (PARS) General: Psychoeducational suicide prevention program designed to be used within Intensive Outpatient Programs Goals: Increased Knowledge and awareness of: Relationship between addiction and suicide Suicide prevention Adaptive attitudes and behaviors toward suicide, suicide prevention, and addiction Voss et al., 2013

31 Treatment Behavioral - learn new behaviors - manage environment Pharmacologic -prevent withdrawal -decrease cravings -allow normal functioning

32 ABC s of Behavior Antecedents - what happened before? Behavior - what did you do? cues triggers stressors what could be done instead? Consequences - what came after? our brains listen most to immediate consequences Ramnero & Torneke 2011

33 Documentation Critical Reasoning in the decision-making process of Why the patient is at risk for suicide What was done (Safety Planning - Content, Response) Crisis information Discussions and approaches to means reduction All communications with the patient, family members, significant others, and other caregivers Follow-up activities taken for missed appointments CDC, 2014

34 Summary Major risk factors for suicidal ideation Co-Occurring Mental Illness and trauma SUD's increase death of suicide by fold Previous suicide attempt is most powerful predictor of eventual death by suicide Screening methods for evaluating suicidal ideation PHQ-9, Interview List key elements of safety planning for patients with suicidal ideation Acute (Emergency Measures) vs. Chronic (CAMS, PARS) Documentation

35 References American Foundation of Suicide Prevention [Accessed 09/15/17] American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fifth Arlington, VA. American Psychiatric Association. Edition. Beghi M, Rosenbaum J. Risk factors for fatal and nonfatal repetition of suicide attempt: a critical appraisal. Curr Opin Psychiatry. 2010;23(4): PMID: Borges G, Angst J, Nock M, et al. A risk index for 12-month suicide attempts in the National Comorbidity Survey Replication (NCS-R). Psychol Med. 2006;36(12): PMID: Brown, GK, Steer, RA, Henriques, GR, and Beck, AT. The internal struggle between the wish to die and the wish to live: a risk factor for suicide. American Journal of Psychiatry (10), CDC National Health Report: Leading Causes of Morbidity and Mortality and Associated Behavioral Protective Factors United States, October 31, 2014 / 63(04);3-27. Available at: Risk and Centers for Disease Control and Prevention (CDC). Web-based Injury Statistics Query and Reporting System (WISQARS) [Online]. (2013) National Center for Injury Prevention and Control, CDC. Available from URL Center for Behavioral Health Statistics and Quality (CBHSQ) Key substance use and mental heatlh indicators in the United States: results from the 2015 National Survey on Drug Use and Health. HHS Publication SMA , NSDUH Series H-51. Retrieved from

36 References Center for Substance Abuse Treatment (CSAT) Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration. Eaton D, Kann L, Kinchen S, et al. Youth risk behavior surveillance United States, MMWR Surveill Summ. 2012;61(4): PMID: Grant BF, Chou PS, Saha TD et al. Prevalence of 12-Month Alcohol Use, High-Risk Drinking,and DSM-IV Alcohol Use Disorder in the United States, to Results From the National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry. 2017;74(9): Jobes DA. The Collaborative Assessment and Management of Suicidality (CAMS): an evolving evidence-based clinical approach to suicidal risk. Suicide Life Threat Behav. 2012;42(6): Joint Commission. Sentinel Event Alert Feb 24;(56):1-7.Detecting and treating suicide ideation in all settings. Kessler R, Borges G, Walters E. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56(7): PMID: Martinez D, Saccone PA, Fei L, et al Deficits in dopamine D2 receptors and presynaptic dopamine in heroin dependence: commonalities and differences with other types of addiction. Biological Psychiatry 71: Nock M, Borges G, Bromet E, et al. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry. 2008;192(2): PMID:

37 References Roy A, Janal. MN. Risk factors for suicide among alcohol-dependent patients. Arch Suicide Res. 2007;11: Roy A. Characteristics of cocaine dependent patients who attempt suicide. Arch Suicide Res. 2009;13: Roy A. Risk factors for attempting suicide in heroin addicts. Suicide Life Threat Behav. 2010;40: Rudd M, Berman A, Joiner T Jr. et al. Warning signs for suicide: theory, research, and clinical applications. Suicide Life Threat Behav 2006; 36 (3): Saha TD, Kerridge BT, Goldstein RB, et al., Nonmedical Prescription Opioid Use and DSM-5 Nonmedical Prescription Opioid Use Disorder in the United States. J Clin Psychiatry. 2016; 77(6): Schmidt A, Borgwardt S, Gerber H, et al Acute effects of heroin on negative emotional processing: relation of amygdala activity and stress-related responses. Biological Psychiatry 76: Shain B and AAP Committee on Adolescence. Suicide and Suicide Attempts in Adolescents. Pediatrics.2016;138(1):e Shea, SC. The Practical Art of Suicide Assessment. Stoddard, NH: Mental Health Presses. Shneidman ES. The Suicidal Mind. Oxford University Press, Wilcox HC, Conner KR, Caine ED. Association of alcohol and drug use disorders and completed suicide: an empirical review of cohort studies. Drug Alcohol Depend. 2004;76:S11 S19. Voss WD, Kaufman E, O Connor SS, et al., Preventing Addiction Related Suicide: A Pilot Study. J Subst Abuse Treat. 2013; 44(5): Yuodelis-Flores C and Ries R. Addiction and suicide: A review. Am J Addict. 2015;24(2):