Suicide Risk Assessment in Medical Encounters

Transcription

1 Suicide Risk Assessment in Medical Encounters Rose McCabe Imren Sterno Stefan Priebe Rebecca Barnes Richard Byng

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3 Nonspecific effects account for 60% outcome in clinical trials d

4 1.8% global burden of disease

5 Potential for prevention through assessment 1 in 4 have had contact with specialists in year before 1 in 2 in contact with primary care in month before death Assessments have additional potential to be therapeutic

6 Risk assessment when healthcare professionals ask about: feelings or thoughts of ending your life feelings or thoughts of harming yourself past events associated with self harm harming others making an attempt on your life (Fremouw, Perczel and Ellis (1990)

7 Research Questions 1. What type of questions do practitioners ask? 2.Does the question influence the patient s response?

8 Primary and secondary care 350 audio/ video recorded visits for depression or schizophrenia Psychiatrists, GPs, CPNs 90 questions (with 84 patients) by 40 professionals 5 of 46 (10.9%) primary care depression consultations 2 of 2 (100%) community mental health team post referral assessments 77 of 350 (22%) specialist mental health care out patient consultations

9 Examples of risk questions Have you had any thoughts of harming yourself? Have you ever become suicidal at all? You don t have thoughts of harming yourself? Yes No Interrogatives

10 Medical question design 1. Establish particular agendas for patient response 2. Embody assumptions about various aspects of patient s health Do you use any drugs? What drugs do you use? 3. How a question is designed expects a specific type of response

11 Constraints of YNIs 1.Invites a Yes/No response Do you take drugs? 2.Invites agreement or disagreement to a candidate answer You don t take drugs do you?

12 Polarity In addition, questions can favour: 1. YES through the use of grammar & positive polarity items (some) Do you have some suicidal thoughts? 2. NO through the use of a negative declarative statement & negative items (any, ever, at all) You don t have any suicidal thoughts?

13 Response options Yes No Narrative

14 Inviting a yes: yes response 01 DOC! do you get lo:w in moo:d <occasionally>? 02 (0.2) 03 PAT!yeah. nods!!!!! 04 DOC yea:h nods sometimes fee:l like life 05 is not worth <living anymore:>. 06 PAT! nods!yeah. nods 07 (0.4) 08 DOC do you get that. 09 PAT yeah.

15 Inviting a no: no response 01! DOC! do you ever (.) think that life isn t worth 02!!! living? 03! (1.4) 04!! PAT! no.

16 Inviting a no: Narrative response 1. Dr do you ever feel yourself (0.4) that you can t go 2. on anymore? 3. (.) 4. Dr do you ever feel yourself that life isn t worth 5. livin[g. 6. P [at the moment I would like (help/it all) to stop some 7. times because its just t- SHIH 8. (.) 9. Dr you d like what. 10. (.) 11. could you say what you d [like. 12. P [all this- all a a 13. I d like it [all to stop sometimes because um 14. Dr [hmmhmm 15. P.shih (0.4) s[ometimes 16. Dr [do you mean by turning your mind off 17. [or do you mean [by (0.2) sort of [actually 18. P [y- [y- [I think that 19. Dr [in a fatalistic sort of way. 20. P [now I jus- I jus- (.) I jus- (0.2).tch 21. sometimes I just- y- you know dread the thought of 22. another day. 23. (.) 24. P because.hhh you know when people go oh it- c- things 25. can t get any wo[rse, 26. Dr [right. 27. P well now I ve got to the stage where I daren t say tha[t 28. Dr [right. 29. P because.hhh things always do [seem to be worse 30. Dr [right. 31. P you know [.hhh me- when the- (.) when the others

17 Inviting a no: Narrative 1. Dr: okay c-.hhh I need to ask you- c- um (0.8) do you- have you 2. ever yourself thought.hhh that you don t want to live anymore? 3. Have you ever actually had suicidal thoughts since [(Gary). 4. P: [.shih I don t 5. really know subconsciously I might have done I don t [really know. 6. Dr: [hmm 7. Dr: so you ve never actually- (.) actually done something= 8. P: =no. no. 9. Dr: c[onsciously o[r objectiv[ely to harm 10. P: [no. [no. [no. 11. Dr: y o [u r s e l f. 12. P: [no. 13. Dr: okay.hhh have you ever had any have you had any other 14. symptoms you d describe to me.hhh (0.4) for example 15. thought (0.2) your mind is playing tricks on you?

18 Findings 1: 90 Questions 64 negative YNIs 26 positive YNIs Twice as likely to ask patient to confirm absence of suicidal ideation Optimisation

19 Distribution of Yes, No and Narrative Responses by Question Type chi square = 6.5, df=1, p=0.013

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21 Number of practitioners Percentage of positive questions

22 Does it matter? For practitioners Subtle difference in wording is important Practitioners not aware If patients respond with a no, no further enquiry For patients Blocking them recounting distress Not facilitating coping

23 Clinical implications Institutional pressure to elicit a yes/no Questions make it more difficult for patients to disclose suicidal thoughts More problematic when used with patients for whom it is more tricky to assess level of risk? Dilemma for patients: despite some suicidal thoughts, deny & compromise care or risk being seen to exaggerate the problem?

24 Why more likely to use negative YNIs? Optimisation Workload implications - need for more in depth assessment, referrals, admissions Reluctance to escalate bureaucratic risk assessment procedures? May not be in patient s best interest

25 Any vs. Some Pa.ents visi.ng GP o3en come with > 1 concern Pa.ents listed concerns before visit Doctors allocated to: A: Is there ANYTHING else you want to address B: Is there SOMETHING else you want to address 20 doctors & 224 pa.ents SOME condi.on eliminated 78% unmet concerns (OR. 154, p=.001) Heritage et al. (2007)

26 Training Suicide risk assessment in specialist mental health care and in A&E in general hospitals (liaison psychiatry) Pre- and post- videos of communication Some participants used more open questioning after training Replacing negative with positive YNI for key suicidal ideation question, as response promotes or closes down further risk assessment

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29 Thanks to All of the people who agreed to be video-recorded