Suicide Assessment In Less than 45 Seconds tinyurl/EnzerGrand

1. Volunteer Associate Professor of PsychiatryUniversity of Cincinnati Medical CenterJuly, 1987 to 2014 Senior AttendingGood Samaritan HospitalDepartment of Psychiatry2002 to Present Suicide Assessment In Less than 45 Seconds http://tinyurl.com/EnzerGrand • Learn about Our Reluctance to Assess Effectively • Learn the Research behind Effective Assessment • Learn How to Assess Suicidality in Less Than 45 Seconds

2. Disclosures • No Potential Conflicts of Interest to Report. • Practiced Psychiatry for about 90,000 Hours. • While Being My Patient, None Have: • Attempted Suicide • Committed Suicide • Among These Patients: • Four Handed Me Knives • Two Handed Me Straight-Edged Barber’s Razors • One Handed Me a Heavy Glass Ashtray • One Handed Me a Revolver • One Submitted to the Police a Uzi Submachine Gun

3. Inpatient Suicide is A Traumatic Event • Often Difficult to Predict • A Relatively Rare Occurrence • Suicide is the Eleventh Leading Cause Of Death in the United States • Approximately 1,500 Suicides Occur in Inpatient Hospital Units in the United States Each Year [41] • Patient Suicide in The Hospital Is One Of The Most Frequently Reported Occurrences Reported To The Joint Commission • From 1995 to 2005, Suicide Was The Most Common Sentinel Event [28]

4. We Can Educate One AnotherWe Can Help Those in NeedWe Can Make a Difference - - - - - • Divide Up into Teams of 4 • Each Team to Have One of these: • 2 Different Professions • 2 Different Levels of Training

5. Ignorance Not trustable We don’t do them They take too long Lack to perform Lacking skill responding What Are Major Problems with Current Suicidality Evaluations ? ? ??

6. Percentage of Hospital Patients Who Self-Harm – Including Suicide Attempts and Suicide -- Come From the Psychiatric Units? • 100% • 75% • 50% • 25%

7. Percentage of Good Sam Patients Who Self-Harm – Including Suicide Attempts and Suicide -- Come From the Psychiatric Units? • 100% • 75% • 50% • 25%

8. Which of These is a Psychiatric Diagnosis: A. Agitation/Agitated B. Anxious C. Depressed/Depression D. Paranoid E. Suicidal/Suicide • A and B • D • C and D • None of the Above • All of the Above

9. Suicides in the Medical/Surgery Settings Do Occur • Suicides Pose Profound Challenges for Patients • Suicides Pose Profound Challenges for Their Families • Suicides Pose Profound Challenges for Health Care Workers • Suicides Pose Profound Challenges for Hospital Administrators [3]

10. Joint Commission’s Sentinel Alert • In 1998, on Preventing Inpatient Suicides. • To Assure That Patients Outside of Psychiatric Units are Appropriately Screened and Managed [1] • About Half of Inpatient Suicides and Suicide Attempts Occur While the Patient Is Not on an Inpatient Psychiatry Unit [32], [26] • At Trihealth, about Half Intentionally Self-Harming Were Not from the Department of Psychiatry. [27]

11. Risk Factors for Suicide • Factors Contributing to Patients Killing Themselves While Admitted to General Hospital Medical/Surgical Units Have Not Been Well Described • Agitation and Impulsiveness Increase the Risk of Imminent Suicide

12. Risk Factors Which May be Absent among Medical/Surgery Patients • Past History of Psychiatric Illness, • Substance Abuse • Suicidality • Suicide Attempts • Present Depression • Known Mental Disorder [18]

13. People Who Are Suicidal May Have: • Depressive Disorders • Psychotic Disorders • Substance Abuse • Anxiety Disorders • 20% of Subjects with Panic Disorder • 12% of Those with Panic Attacks [40], [21] • Personality Disorders • Organic Disorders • No Mental Disorder

14. Risk Factors: • Risk Factors are More Stable • Risk Factors are Distal in Their Relationship to Suicidal Behavior

15. Most Suicide Risk Factors Have Very Little Clinical Relevance: • Risk Factors range Over 1 Year to More Than 20 Years • Clinicians are Worried about Decisions Over: • The Next Few Days • The Next Few Hours • The Next Few Minutes • Not Years

16. Warning Signs for Potential Suicidal Behavior are Far More Useful: • Immediately Observable • Implicate Current Functioning • Warning Signs Help to Answer the Critical Questions: • What is My Patient Doing (Observable Signs) • What is My Patient Saying (Expressed Symptoms)

17. Warning Signs Elevate the Risk of Dying by Suicide to: • The Next Few Days? • The Next Few Hours • The Next Few Minutes [5]

18. Plan Prior attempt Ideation Action Sudden behavior change Extreme happiness Giving things away Warning Signs Suggesting Suicide Imminent ? ? ? ??

19. Warning Signs Suggesting Increased Desperation and Imminent Risk:[1] • Agitation • Complaining of Unrelenting Pain • Crying Spells • Refusing Medications • Decreased Emotional Reactivity • Impulsivity • Increased Anxiety or Panic • Irritability

20. More Warning Signs Suggesting Increased Desperation and Imminent Risk:[1] • Refusing Visitors • Requesting Early Discharge Decreased Interest in Prognosis • Decreased Interest in Treatment • Feelings of Worthlessness • Helplessness • Hopelessness • Refusing to Eat

21. Suicidal General Hospital Patients Unlike Psychiatric Inpatients: [11] • Attempt Suicide after Admission More Rapidly • Attempt Suicide after Admission with little Threats • Attempt Suicide after Admission with little Warnings

22. Suicide Prevention on Medical/Surgical Units Should Emphasize: [33] • Focusing on Behavioral Warning Signs of Imminent Danger: • Agitation • Irritability • Patient Assessment

23. To Prevent Suicide in the Med/Surg Environment [6] • Appreciate the Potential Lethality of Acute Psychic and Motoric Agitation • Rather than Surveillance of Agitated Patients • Calm Them with: • Soothing Lighting • Soothing Music • Soothing Aroma • Soothing Massage • Secure Their Surroundings • Psychiatric Nursing Consultation

24. These Patients Need Regular Assessment: [24] • Patients Recovering from A Suicide Attempt • Patients with Delirium or Dementia When Either Agitated or Impulsive • Patients Overwhelmed by Their Illness or Disability

25. The Relationship Between Suicide & Mental Illnesses Is Confusing: [18] • Medication Can Reduce Depressive Symptoms without Reducing Suicidality • Only Lithium Has Evidence for Reducing Suicidality • Suicide Is an Adverse Effect of about 200 Medications • Psychotherapy Can Reduce Suicide Without Changing Affective Symptoms • Over 95% of Those with Mental Disorders Do Not Complete Suicide

26. Research Shows so-called No-Suicide Contracts are Not Effective [14]

27. Family History Previous attempts Trick question Name a Suicide Predictor ? ? ? ??

28. Suicide Predictors Ranked: [15] • Depressive Disorders are the Least Predictive • Suicidal Ideation is a Better Predictor Than Depressive Disorders • Hopelessness is the Strongest Predictor

29. Reasons Clinicians Reluctant to Evaluate for Suicidality ? ? ? ?? • Time required • Not always effective • Legal issues

30. We are Reluctant to Evaluate for Suicidality: • Fear/Anxiety about Addressing Death • Anxiety of Getting Close to Dying Patients • “I Will Become Emotionally too Close” • Reluctance to Talk Openly • Enquiry Will Unleash Uncontrollable Emotions • Discussing Patients Concerns is of No Benefit to Patients • Death/Depression Is Inevitable/Untreatable • Discussing Patient Concerns is of No Benefit Professionally or to Our Role as Givers of Care

31. Just ask Open ended question What are your thoughts about ending your life? If you had a means, would you commit suicide? Assess for irritability, etc. Any thoughts of harming yourself? Previous attempts? How to Screen for Suicidality ? ? ??

32. Men > women Most want to die Leave a note Previous attempts Women attempt more, men are more successful Dx psych illness False Suicidality Myths ? ? ? ??

33. False Suicide Myths • Discussing Suicide “Gives the Patients Ideas” [16] • Patients Who Repeatedly Make Suicide Threats Don’t Really Want to Die [17] • A History of Prior Attempts Means That the Patient Is Not Serious [18] • Depression Is A Normal Reaction to Medical Illness • Wanting to Die Is Common In the Seriously Ill Patient [19], [20] • Suicidality and Depression Will Simply Fade Away with Time

34. Ask about Suicidality Directly: [21] • The Most Effective Method of Uncovering Thoughts of Self-Harm • Just as Important for Givers of Care to Be Able to Ask about Suicide • As to Query Other Discomforting Topics • Sexual History • Substance Abuse • Domestic Violence • The Importance of Learning This Skill Cannot be Overstated

35. Suicide Assessment in less than45 Seconds • Recency • Aggravating Social Pressure • Tug towards Life • Immediacy

36. Evidenced Based Questions and Procedures: • High Sensitivity • True Positive Rate High • False Negative Rate Low • High Specificity • True Negative Rate High • False Positive Rate Low

37. Assessment for Suicidality: • Must Be Focused • Must Be Clinically Relevant • Must Be Evidence Based • Must Be Acceptable to the Busy Clinician

38. Questions Evaluated to Detect a Suicide Plan [22] • “Thoughts of Death” • 100% Sensitive • 81% Specific in Discovering Suicidality • “Feeling Suicidal” • 83% Sensitive • 98% Specific • “Do You Wish That You Were Dead?” • 92% Sensitive • 93% Specific

39. Indirect Questions Make it Easier to Say Everything General Principles of Effective Interviewing: • Avoid Asking Direct Questions • Indirect Questions Ease Talking about Sensitive Matters • Universalize • “Many People. . . ..” • “People Who Have – Name the Disorder/Complaint. . . ..” • Use a Time Reference • “I Wonder When was the First Time You. . . ..” • “I Wonder When was the Last Time You. . . ..”

40. 1. Assess Recency of Suicidal Urges • People with [Disease/Complaint] from Time to Time, Think about Suicide • I Wonder When Was the Last Time You Thought "I'd be Better off out of the Picture, Dead – about Suicide"

41. 2. If Suicidal Ideation Recent -- Assess Aggravating Social Pressure to Suicide I Wonder, Who Else Would be Better Off With You Out of the Picture, Dead

42. 3. If Suicidal Ideation Recent -- Assess Tasks that Resist Suicide I Wonder What Are Your Reasons -- if any -- That You Have Decidedto Live TODAY • Only Tasks, or Unfinished Business, or Obligations -- Count • None of these are Tasks: • Moral Reasons • Philosophical Reasons • Religious Reasons

43. 4. If Suicidal Ideation Recent -- Assess Immediacy of  Suicide I Wonder How Much Time Do We Have before You Kill Yourself ? • A year ? • A month ? • A week ? • A day ? • An hour ? • Minutes ?

44. Doctoring Is An Artful Skill: • Boundless in Its Potential • Providing Suicide Risk Assessment to All Patients • Another Step in Realizing Our Potential

45. Key to Our Being Experienced as Providing Quality Care: • Being Curious • Being Thorough • Enjoying the Patient • Enjoying Providing Care

46. What Are You Now Will to Do Differently in the Future – Even Just Once ? ? ? ??

47. -- Goodies –http://tinyurl.com/EnzerGrand Click on: • PowerPoint Presentation • Print Handout of All Slides • Print Handout of Just Slides with Notes • Citations and Sources Consulted

48. "Prescribing Is So Easy, Understanding People So Hard." Kafka, Franz. (1917) A Country Doctor. The Penal Colony, Stories and Short Pieces (translated by W. & E. Muir, 1961), p. 140. New York: Shocken Books.