Screening for Depression and Suicide Risk Assessment

Screening for Depression and Suicide Risk Assessment Karl Rosston, LCSW Suicide Prevention Coordinator (406) 444-3349 krosston@mt.gov Updated: July, 2017

Suicide Fact Sheet Center for Disease Control WISQARS website, http://www.cdc.gov/injury/wisqars/index.html, (January, 2017) Suicide has surpassed car accidents as the No. 1 cause of injury-related death in the United States. There has been a 28% increase in the number of suicides in the United States since 2001 (CDC, 2016) In 2015 there were 44,193 suicides in the U.S. (121 suicides per day; 1 suicide every 12 minutes). This translates to an annual suicide rate of 13.8 per 100,000. Males complete suicide at a rate four times that of females. However, females attempt suicide three times more often than males. Firearms remain the most commonly used suicide method, accounting for nearly 50% of all completed suicides.

Suicide and Primary Care Up to 45% of individuals who die by suicide visit their primary care provider within a month of their death, with 20% of those having visited their primary care provider within 24 hours of their death Elders who complete suicide: 73% have contact with primary care physician within a month of their suicide, with nearly half visiting in the preceding week. There is a strong correlation between chronic pain and suicide 20-30% of those who die by suicide have issues of chronic illness or pain. A person with chronic pain is 3 times the risk of suicide

Montana Suicides with identified Warning Signs In the 74% of the suicides where warning signs were identified, at least 3 warning signs were present in each suicide. No Identified Warning Signs, 144, 26% Warning Signs Identified, 411, 74%

Suicide in Montana Data Source: CDC-WISQARS (1/27/17), Montana Suicide Mortality Review Team (June, 2016) For all age groups, Montana has ranked in the top five for suicide rates in the nation, for the past forty years. According to the most recent numbers released by the National Vital Statistics Report for 2015, Montana has the third highest rate of suicide in the United States (272 suicides for a rate of 26.3). Between January 1, 2014 and July 14, 2017, Montana had 974 suicides for a rate of 28.5

Approximately 90% of those who complete suicide suffer from at least one major psychiatric disorder Mood disorders are consistently the most prevalent disorder (49-64%) The 2 nd most frequent diagnosis is a Substance abuse disorder. (however, it is important to note that not all mentally ill people attempt suicide) Montana Suicides with Identified Mental Health Issues Mental Health Issues, 261, 83% Montana Suicides By Type of Mental Health Disorder Anxiety, 21, 7% Other, 15, 5% Psychotic Disorder, 9, 3% PTSD, 22, 8% Bipolar, 24, 8% None Reported, 52, 17% Based on 313 suicides that provided mental health information 55 of the 261 (21%) had multiple mental health issues. Depression, 202, 69%

Depression is Treatable Depression is one of the most treatable of all psychiatric disorders in young people 86% treatment rate with a combination of antidepressants and therapy* Only between 40-70% with either by themselves. * Source: The TADS Team. The Treatment for Adolescents with Depression Study (TADS): Long-term Effectiveness and Safety Outcomes. Archives of General Psychiatry. Oct 2007; VOL 64(10).

The estimation of suicide risk, at the culmination of the suicide assessment, is the quintessential clinical judgment, since no study has identified one specific risk factor or set of risk factors as specifically predictive of suicide or other suicidal behavior. From The American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors, page 24.

For a tentative diagnosis of depression; Questions 1 or 2 are endorsed in the shaded area. If there are at least 4 checks in the shaded section (including Questions #1 and #2), consider a depressive disorder. if there are at least 5 checks in the shaded section (one of which corresponds to Question #1 or #2), consider Major Depressive Disorder (a dx of MDD indicates 25x the risk of suicide.) Shaded response to question #9 indicates 10x the risk of suicide

Interpretation of Total Score Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up Ideation Severity Subscale Questions 1-5: Five types of ideation of increasing severity Score presence/absence of any suicidal ideation yes/no Questions 1 &2 are screening questions; if the answers to both are no, you do not need to ask questions 3-5 and may skip to the suicidal behavior section. The most severe ideation endorsed (1-5) becomes the score for this section. Bottom section provides history, presenting symptoms, and stressors.

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up Intensity of Ideation Subscale (Referring only to the most severe ideation endorsed above for the timeframe of interest): Add the highest numbers endorsed on the 5 intensity items (Frequency, Duration, Controllability, Deterrents, and Reasons for Ideation). The sum ranges from 2 to 25, with the higher number indicating more intense ideation. If no ideation was endorsed on the Severity Subscale, assign a score of 0 or N/A for the Intensity Subscale.

INTENSITY OF IDEATION The following features should be rated with respect to the most severe type of ideation (i.e.,1-5 from above, with 1 being the least severe and 5 being the most severe ). Ask about time he/she was feeling the most suicidal. Most Severe Ideation: Type # (1-5) Description of Ideation Frequency How many times have you had these thoughts? (1) Less than once a week (2) Once a week (3) 2-5 times in week (4) Daily or almost daily (5) Many times each day Duration When you have the thoughts, how long do they last? (1) Fleeting - few seconds or minutes (4) 4-8 hours/most of day (2) Less than 1 hour/some of the time (5) More than 8 hours/persistent or continuous (3) 1-4 hours/a lot of time Controllability Could /can you stop thinking about killing yourself or wanting to die if you want to? (1) Easily able to control thoughts (4) Can control thoughts with a lot of difficulty (2) Can control thoughts with little difficulty (5) Unable to control thoughts (3) Can control thoughts with some difficulty (0) Does not attempt to control thoughts Deterrents Are there things - anyone or anything (e.g. family, religion, pain of death) - that stopped you from wanting to die or acting on thoughts of committing suicide? (1) Deterrents definitely stopped you from attempting suicide (4) Deterrents most likely did not stop you (2) Deterrents probably stopped you (5) Deterrents definitely did not stop you (3) Uncertain that deterrents stopped you (0) Does not apply Reasons for Ideation What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it to end the pain or stop the way you were feeling (in other words you couldn t go on living with this pain or how you were feeling) or was it to get attention, revenge or a reaction from others? Or both? (1) Completely to get attention, revenge or a reaction from others. (4) Mostly to end or stop the pain (you couldn t go on (2) Mostly to get attention, revenge or a reaction from others. living with the pain or how you were feeling). (3) Equally to get attention, revenge or a reaction from others (5) Completely to end or stop the pain (you couldn t go on and to end/stop the pain. living with the pain or how you were feeling). (0) Does not apply Most Severe 13

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up There are no cut off score for intensity. That said, we do have the following data that looked at ranges of scores and risk ratios for suicide behavior and found a 34X increase for the 21-25 range with lower odds ratios as the score range drops. These scores are best used to help inform clinical judgment when there is uncertainty about disposition and to assess change over time. Moderate (6-10) Mod. Severe (11-15) Severe (16-20) Very Severe (21-25) 11x 13x 19x 34x

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up Suicidal Behavior Subscale: 4 types of suicidal behaviors are scored yes/no and identify categorical occurrence and density of actual, interrupted, aborted attempts and preparatory behaviors and distinguish suicidal and non-suicidal self injurious behavior. Presence of an attempt is a number one risk factor for dying by suicide Number of suicidal behaviors the total number of each type of suicidal behavior that occurred during the given time period shows the density of suicidal behavior (more behaviors represents higher degree of risk for example, multiple attempters are more at risk than single attempters).

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up High Risk Suicidal ideation with intent or intent with plan in past month (C-SSRS Suicidal Ideation #4 or #5) Or Suicidal behavior within past 3 months (C-SSRS Suicidal Behavior)

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up High Risk Triage Refer to Psychologist or Psychiatrist to evaluate for hospitalization Place on Facility High Risk List

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up High Risk Possible Interventions Assessment of patient s medical stability Observation Status Elopement precautions Body/belongings search Pharmacological treatment Family/significant-other engagement Psychotherapy (CBT, DBT) Psychoeducation (coping skills, stress management, symptom management, etc.) Safety Plan Telephone Follow-up upon discharge

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up High Risk Possible Interventions Safety needs to consider in the physical environment: Assess the physical environment, focusing on limiting access to methods. The most common methods of suicide in hospitals are hanging, suffocation and jumping. If risk assessment is conducted in outpatient setting: Place individual in a room that is away from exits but close to staff where patient is observed at all times Beware of elopement risk if patient is against admission AND/OR wanting to be alone to follow through with plans of suicide

SAFE-T Protocol with C-SSRS, Safety Planning and Telephone Follow-up General Guidelines for; Treatment plan for reducing risk level Suicide risk following discharge from inpatient setting Community Prevention Practices Guidelines for when to document suicide risk assessment

Depression is Treatable Suicide is Preventable If you are in crisis and want help, call the Montana Suicide Prevention Lifeline, 24/7, at 1-800-273-TALK (1-800-273-8255) or text MT to 741 741 www.dphhs.mt.gov/amdd/suicide