Psychiatry for General Practitioners Study Days 2017 December 13th 2017 Suicide Risk Assessment Keith Hawton
Psychiatry for General Practitioners Study Days 2017 December 13th 2017 Suicide Risk Assessment: Moving from the Impossible to Suicide Prevention Keith Hawton
The problem of trying to predict risk of suicidal behaviour Risk prediction does not work
Prediction of Suicide
Assessment of risk prior to suicide
Assessment of risk prior to suicide
Empirical Data Regarding Those Who Die by Suicide The majority of patients who die by suicide actually deny having suicidal thoughts when last asked prior to their death, OR communicate their risk in more behavioural ways vs. verbal messaging Appleby L, et al. BMJ. 1999;318(7193):1235-1239. Barraclough B, et al. Br J Psychiatry. 1974;125(0):355-373 Busch KA, et al. J Clin Psychiatry. 2003;64(1):14-19. Chavan BS, et al. Indian J Psychiatry. 2008;50(1):34-38. DeLong WB, et al. Am J Psychiatry. 1961;117(8):695-701. Hall RC, et al. Psychosomatics. 1999;40(1):18-27. Hjemeland H, et al. Soc Psychiatry Psychiatr Epidemiol. 1996;31(5):272-283. Isometsä ET, et al. Am J Psychiatry. 1995;152(6):919-922. McKelvey RS, et al. Aust N Z J Psychiatry. 1998;32(3):344-348.
Prediction of Repetition of Self-harm
Assessment of risk following self-harm Risk (N) n (%) repeating self-harm Low (1721) 165 (9.6) Moderate (1738) 288 (16.6) High (369) 95 (25.7) (Kapur et al BMJ 2005)
Assessment of risk following self-harm Risk (N) n (%) repeating self-harm Low (1721) 165 (9.6) Moderate(1738) 288 (16.6) High (369) 95 (25.7) (Kapur et al BMJ 2005)
126 consecutive patients admitted to the John Radcliffe 11 Hospital following selfharm
A scale developed in 1983 by Patterson et al in Canada for teaching medical students about assessment of suicide risk Based on the 10 major risk factors for suicide: Sex (Male) Age (<19 or >45) Depression Previous attempts Ethanol abuse Rational thinking loss Social supports lacking Organised plan No spouse Sickness
Scoring: 1 point for each factor 0 = very low risk 10 = very high risk 0-2 send home with follow up 3-4 close follow up; consider hospitalisation 5-6 strongly consider hospitalisation 7-10 hospitalise
SADPERSONS score < 7 SADPERSONS score 7 Referral to secondary care (N=69) Psychiatric inpatient care (N=5) 65 (94.2%) 4 (5.8%) 4 (80%) 1 (20%) Repetition of selfharm within 6 months (N=30) 28 (93.3%) 2 (6.7%)
SADPERSONS missed: 65/70 referrals to 2 o care 4/5 admissions to psychiatric hospital 28/31 who repeated SH at 6/12
Risk tools and scales
Risk tools and scales Risk tools and scales to predict suicide after self-harm: Positive Predictive Value about 5% So they are wrong 95% of the time And they miss suicide deaths in the large low risk group
Risk tools and scales UK NICE Guidelines (2011) Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm. Do not use risk assessment tools and scales to determine who should be offered treatment or who should be discharged. Risk assessment tools may be considered to help structure, prompt, or add detail to assessment.
Limitations of Solely Relying on Risk Factors The problem with using risk factors to assess the probability of suicide is that they all produce high false negatives. We have never been very good at predicting the future especially for low-base rate behaviours.
What is the best alternative to risk prediction? Recognise that risk prediction is a fallacy Address patient needs Focus on the therapeutic aspects of the assessment Use clinical guidelines and make evidence based treatments available Individualised assessment which informs management Adopt population approaches to prevention something for everyone
Population approach
Assessment, Not Prediction The goal is to assess the patient and use information to plan for safety and treatment The clinician cannot Assign weights to risk and protective factors Subtract the protective factors from the risk factor, thereby getting the net suicide risk The clinician can Use a process of progressive questioning to gather relevant information to inform a risk formulation that leads to an individualized intervention
Suicide Risk Formulation
A Typical Risk Formulation Approach (Prediction Model) Variable\Rating Nominal Low Moderate High Ideation None reported Passive wishes, Fleeting thoughts Some thoughts Active and/or pervasive thoughts A Typical Risk Formulation Approach Plan None reported No plan Vague plan Specific plan Lethality None reported Low Potentially lethal Lethal Access None reported Limited Accessible Possesses Intent None reported Vague Some Desires to die
Pisani AR, et al. Reformulating Risk Formulation: From Prediction to Prevention. Acad Psych, 2015.
Managing risk Focus on individualised risk reduction in all patients e.g. - safety planning - evidenced-based treatments - therapeutic relationship - involvement of family and others - reduced access to means - clear and communicated plans
Acknowledgements Professor Nav Kapur (Manchester) Dr Morton Silverman (USA) This presentation discusses independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0606-1247, RP-PG-0610-10026) and Policy Research Programme. The views expressed in this presentation are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health.
Psychiatry for General Practitioners Study Days 2017 December 13th 2017 Suicide Risk Assessment: Moving from the Impossible to Suicide Prevention Keith Hawton