Suicide Risk Assessment, Management and Documentation

Transcription

1 Suicide Risk Assessment, Management and Documentation JIMMIE D. MCADAMS, DO DFAPA Laureate Psychiatric Clinic and Hospital Director Senior Behavioral Health Jeff Mitchell, M.D. Matthew Meyer, M.D. Phillip Leon, M.D. Scott Grantham, M.D. 1

2 1. Identify essential elements in a risk assessment 2. Identify the most important times in an episode of care when risk should be assessed and documented 3. Identify the key elements in risk assessment documentation 10 th ranking cause of death in U.S. overall 2 nd ranking cause of death ages /100,000 in 2013 Rate is gradually increasing (12.9/100,000 in 2012) 1:64 Americans is a survivor of suicide Rate in men remains roughly 3.5 times that in women (although women attempt more often) Highest rate in the years of age group 2

3 g_causes_of_death_by_age_group_2014 a.pdf 3

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7 17.3/100,000 Rate decreased (17.6/100,000 in 2012) Drug overdose deaths have risen 470 deaths in deaths in deaths in 2013 Most involved prescription drugs Drug overdose deaths outnumber motor vehicle fatalities in Oklahoma 2014* 731 suicides in Oklahoma per ME 7

8 Johnston County 26.57/100,000 Tulsa County 16.68/100,000 Oklahoma County 15.26/100,000 Woods County 7.41/100,000 1) Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide. 2) Address the patient s immediate safety needs and most appropriate setting for treatment. 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 his or her family. 8

9 The rate is too low, even in psychiatric populations For example, the highest risk group, previous suicide attempters, has a risk of committing suicide some time within the next year of 0.5% No method of suicide risk assessment can reliably identify who will commit suicide (sensitivity) and who will not (specificity). But risk can be assessed and stratified Suicide is the result of multiple factors, including diagnosis (psychiatric and medical), psychodynamic, genetic, familial, occupational, environmental, social, cultural, existential, and chance factors. The overall purpose is to identify modifiable and treatable risk and protective factors that inform the patient s overall treatment and management requirements. Help determine the need for immediate measures Help determine level of care needed (IPT/IOP/OPT) Develop a treatment plan that enhances protective factors and mitigates risk factors 9

10 Crisis evaluation Intake evaluation (inpatient or outpatient) After a suicide attempt Patient s mental status / conditions / presentation makes an abrupt change (better or worse) Family, others report change in behavior, suicidal thoughts or behaviors Change in observation status (1:1, SP) Onset of physical illness (especially life threatening, disfiguring, associated with severe pain, or loss of executive functioning) Anticipation or experience of a significant interpersonal loss or psychosocial stressor Prior to discharge Current presentation of suicidality Presence of psychiatric disorder Pertinent history especially suicidal behaviors Psychosocial situation Support Employment Religious/cultural issues Coping skills Impulsiveness Insight Past responses to stress 10

11 Suicidal Thoughts Frequency Intensity Psychotic features e.g., voices Suicidal Plans Frequency Intensity Lethality (expectation of lethality) Access/feasibility (e.g., guns in home, med stockpile) Suicidal Behaviors Rehearsing Attempts Suicidal Intent Substance use in current presentation Presence of hopelessness, anhedonia, panic attacks The likelihood that a particular method will succeed May be different than the perception of lethality Guns, hanging Overdose depends on the substance Acetaminophen, aspirin Insulin, beta blockers Tricyclic antidepressants, lithium Drug/ETOH combinations Assess access to means and document plans to restrict access 11

12 Planning the act Plan is detailed (e.g., time, place, etc) Plan/method is feasible, realistic Means are available Means are lethal (gun, hanging, toxic drugs/chemicals, etc) Practicing/rehearsing the act (putting gun to head) Taking steps to enact (buying a gun, hoarding pills) Taking steps to avoid detection (waiting for spouse to leave) Giving away possessions Writing will Saying goodbye Suicide note Disorder SMR (SMR of general population is 1) Prior Suicide Attempts Bipolar II 24.1 Bipolar I 17.1 Major Depression Eating Disorders Opioid Abuse Obsessive Compulsive Disorder Panic Disorder Schizophrenia 8.45 Personality Disorders 7.08 AIDS 6.58 Epilepsy 5.11 Spinal Cord Injury 3.82 Intellectual Disability 0.88 SMR: standard mortality ratio 12

13 Hopelessness Psychic Pain Severe or unremitting anxiety Impulsiveness Sleep disturbance Substance abuse Shame or humiliation Loss of executive function Polarized, black and white thinking Agitation Panic Attacks Cluster B Personality (use suicide as a coping skill) Physical or sexual abuse Family history of suicide, particularly in first degree relatives 13

14 Acute psychosocial crises losses financial difficulties family discord/domestic violence sexual or physical abuse Employment status Living situation lack of social support (including living alone) children in the home (+) presence (+)/absence of external supports quality of family relationships (+/ ) Cultural/religious beliefs about death or suicide (+) Pregnancy (+) Sense of responsibility (+) Positive therapeutic relationship (+) Positive problem solving skills and coping skills (+) Reality testing ability (+) Protective factors are those features that counteract the risk factors May be instrumental in the decision to hospitalize/not hospitalize A patient may have many risk factors, but strong protective factors can result in a referral for outpatient services 14

15 Sources of collateral information Potential protective factors Potential risk factors (abuse, toxic relationships) Potential participants in safety planning Patient safety is most important Attempt to get consent Document reasoning and risk The burden of proof for involuntary detention is reason to believe 15

16 Hospitalization? No formula/written standard Risk factors outweigh protective factors Less restrictive options Partial hospitalization: patient has acute symptoms, but good support system Intensive outpatient therapy: patient must be motivated and have adequate resources Outpatient appointment within 7 days Safety plan Agreement to call if in crisis Follow up/no show calls Major Weaknesses of the Suicide Prevention Contract Contracts NOT legally binding Do not protect against legal liability Lack of evidence based support APA: overvalued as a clinical or risk management technique May result in false confidence about patient safety 16

17 Seriously mentally ill patient in acute stages of illness not likely competent to enter into contract Recently admitted inpatient unlikely to have trusting therapeutic relationship with contracting clinician Ignores fundamental understanding of the suicidal mind eg., fraught with ambivalence, difficulty making decisions, distorted judgment Asks the fragile/vulnerable patient to bear the burden of a life threatening responsibility Patient determined to commit suicide views staff as adversary, not ally Joint effort with MH professional, patient, support system when available Elements Reasons for living Removal of means for self harm Description of support system Resources, coping skills patient will use to manage suicidal thoughts urges Follow up, urgent care Plan for what patient will do if these don t work Professional s judgment about the sincerity and thought that goes into the plan can be an assessment factor 17

18 If in doubt, assess the patient Your office Clinical Assessment Department (CAD) Home based assessment (COPES) Unmodifiable risk factors e.g., demographic variables, history of suicide in family, abuse history, financial troubles, unemployment status, others Modifiable risk factors e.g., hopelessness, suicidal thoughts, agitation, anxiety, insomnia, purposelessness, lack of support 18

19 Assess the need for higher level of care The more risk factors, the more you need to address modifiable factors and fortify protective factors Document that you considered these in your assessment of risk legal ramifications: it demonstrates that you provided a thorough screening Caveat: it is impossible to assess all risk factors listed in APA Guidelines, but document all the ones you did assess Anxiety Agitation Hopelessness (correlates more with risk than depression) Insomnia (correlates with suicide risk in mood disorders) Mood lability Hallucinations Delusions Withdrawal symptoms Access to lethal means (guns, pills) 19

20 Short term risk factors are predominantly severe, anxiety driven, and treatable panic attacks psychic anxiety loss of pleasure and interest alcohol abuse diminished concentration insomnia Assess (and document) suicidality on a daily basis Mood status, changes Psychomotor activity Commitment to safety planning Reasons for living Hopefulness Plans or future Status of protective factors Status of modifiable risk factors 20

21 Good care, followed by good documentation, is your best malpractice defense If your patient is in crisis or on an inpatient acute unit, document changes (or lack thereof) in risk at every encounter Assess/document risk at critical junctures in care Patient leaves inpatient unit Lower precaution level Discharge follow up appointment in clinic Suicidal ideation reported, but patient not admitted We are usually good at documenting what we saw and what we did We are generally not as good at documenting why we did the things we did: Why did we let the patient leave the office, leave the unit, move to a lower precaution level? What we write is more important than how much we write 21

22 The only suicidal person is a person who is in the act of attempting suicide. Short of that, he is a person at risk for suicide because of his thoughts or behaviors. To the lay public, Mr. Jones was referred to this clinic because he was suicidal, implies a sense of permanence the author might not have intended. Especially if Mr. Jones eventually commits suicide. Suicide risk fluctuates by the day, hour or minute. Ok to use suicidal to describe thoughts, behaviors, plans but not a person Be thoughtful when using risk level descriptors ( low, moderate, high ) Quantifies suicidal ideation and behavior Validated in adolescent and adult populations Evidence supports that CSSRS can help predict suicide attempts in adolescent and adult populations Used by CDC e version (ec SSRS) utilized by Oklahoma Department of Mental Health and Substance Abuse 22

23 ard_mental_health_professionals.pdf You will rarely feel totally comfortable discharging a patient in crisis or letting him/her leave your office And, no matter how competent you are, you are likely to have a patient who commits suicide Also, you will make mistakes Moreover, you may even make mistakes with patients who eventually commit suicide If an untoward event occurs: Courts will not hold a clinician liable for being wrong about the level of risk a patient presents, as long as the clinician s mistake was based on a reasonable level of care, including documented evidence of the decision making processes that led to treatment planning. Dana Baerger, PhD; Risk Management With the Suicidal Patient: Lessons in Case Law in Professional Psychology: Research and Practice,

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