Suicide Risk Assessment in the ED

1. Suicide Risk Assessment in the ED • A practical approach for emergency physicians • Robert Orman, MD

2. Is this important?

5. References and show notes • www.ercast.org • references, mnemonic card, documentation template • This is a new method • get the flavor, use it, make it your own • Thanks to Jeff Young MD • Lecture references References Here

7. Topics • Why is this challenging? • How can we do it better? • Special circumstances

8. The challenge

9. Residency • Case: Isolated suicidal ideation (SI) • How often do you evaluate suicide risk? • Med clearance, medical management • What questions to ask in SI

10. The Challenges • No gold standard test • Qualitative and descriptive not binary decision • yes/no versus maybe • Less training than with medical emergencies

11. The Reality • The ED is a busy place • You are the rate limiting step • Thorough, focused, organized = good • Haphazard, different every time = bad

12. Estimate = Predict • What questions to ask • Estimate risk • Estimate = Predict • Communicate with patient, family, friends • conclusion script, no certainty

13. Documentation • Risk assessment paragraph • most mental health patients you see • Not long or complicated • organized • reflect your thought process

14. The Method:documentation • Suicide risk assessment.... • 1. Risk factors/warning signs • 2. Protective factors • 3. Collateral information • 4. Estimate of suicide risk • 5. The plan

15. The Method:documentation • 1. Risk factors/Warning signs • increase chance of suicide • "Mr. X presents with multiple risk factors including...”

16. The Method:documentation • 2. Protective factors • decrease chance of suicide • "There are some protective elements, such as..."

17. The Method:documentation • 3. Collateral information • Who else did you talk with about the current situation? 52

18. The Method:documentation • 4. Your estimate of suicide risk • "My conservative estimate of this patient’s suicide risk is... (low, medium, high) • Risk is a continuum, shades of gray • Not a teeter totter or scale

19. The Method:documentation • 4. Your estimate of suicide risk is based on: • Risk and protective factors • Extent of support • Change of condition in ED (better or worse) • YOUR CLINICAL JUDGEMENT 52

20. The Method:documentation • 5. The Plan • Discharged? What to do if increased SI • Admit? Why • How does plan mitigate immediate suicide risk? • Partner with family, friends • "Contracts for safety" = Magical thinking

21. The Method:documentation • Suicide risk assessment.... • 1. Risk factors/warning signs • 2. Protective factors • 3. Collateral information • 4. Estimate of suicide risk • 5. The plan

22. How do we acquire and synthesize all of this information?

23. The Method:decision tools • PERC, Ottawa Ankle rules, Wells score • Guide workup, treatment, disposition • Do decision tools work for SI? 7,11,26,30,35

24. The Method:decision tools • Suicide risk scores • not effective for quantitative risk measurement 7,11,26,30,35

25. The Method:decision tools • What good are they? • Bring together common risk factors • Consistent/thorough line of questions • Clinical judgment rules the day • NOT a number or score 7,11,26,30,35,38

26. The Method:decision tools • SAD PERSONS most studied in ED • Quantitative risk score :-( • No protective factors :-( • Easy to remember what to ask :-) 7,24,29,37-39

27. The Method:next generation • SAD PERSONS as question base • Some parts taken out • New ones added • Information collected • more complete picture of suicide risk • TRAAPPED SILO SAFE 7,24,29,37-39

28. TRAAPPED SILO SAFE • High yield • Baseline/chronic risk factors • Warning signs/acute risk factors • Protective factors

29. Chronic vs Acute risk factors • Baseline/chronic can't be changed • age, previous attempts, previous hospitalizations • Warning signs/acute --> destabilize pt. • May be amenable to intervention • agitation, worsening depression, acute suicidal ideation 42

30. Trigger • Event or circumstance that led to this • Subjective perception more important than quantity or type • avoid judgment of triviality • Anything that acts as acute stressor • Acute/destabilizing risk factor 8,15,36

31. Trigger • Loss. Loss of a Job, relationship, financial support, loved one • Disappointment or embarrassment • Anniversary of significant interpersonal loss • Recent (failed) psychiatric admission or suicide attempt • In teenagers, recent suicide by a peer

32. Rational Thinking Loss • Red flag. High yield • Acute tx can have a significant impact • Psychosis, agitation, debilitating anxiety • Eval and treat versus H&P 5

33. Rational Thinking Loss • More severe symptoms=increased risk • Unlikely to discharge but still need to tx • risk in hospital • After tx, risk estimate may change 5

34. Age • Not a protective factor • Two groups to watch for. >65 and 15-24 • Elderly less warning, more lethal • Elderly 4:1, young 200:1 • Suicide 3rd leading cause of death in 15-24 8,15,17,23

35. Access to means • Many paths to suicide, but... • Limit availability of potentially lethal methods • meds • firearms 6,36

36. Access to means • Why are firearms important? • 60% of suicide deaths in US • #1 modality all age groups, gender

37. Access to means

38. Previous Attempts • Reflex to doubt veracity of SI with previous attempts • 38x suicide risk • Higher in 1st year after • Ask about most lethal previous attempt • breaking the barrier

39. Previous Psychiatric Care • “Have you ever been hospitalized for mental health issues?” • proxy for severity of underlying mental illness • Recent hospitalization • destabilizing • increases risk

40. Previous Psychiatric Care • Does hospitalization protect from self harm? • Why admit in the first place? • manage acute issues • not a panacea • can increase risk

41. Excessive EtOH/Drugs • 50% of suicides +EtOH • Acute intoxication • often part of attempt substrate • impulsive • many don't remember when sober • Used in conjunction with attempt=increased future attempts and suicide

42. Excessive EtOH/Drugs • What about SI when drunk, denies when sober? • Still at risk • Chem dependency needs to be part of dispo plan • Cases

43. Depression

44. Depression • Increase severity = increased risk • Hopelessness = Red flag • May indicate more severe depression • end point of ‘no other way out’ • Less severe = less risk (but not zero)

45. Risk factors so far • Trigger • Rational thinking loss • Age • Access to means • Previous attempt • Previous psych care • Excessive EtOH/Drugs • Depression/Hopelessness

46. Sickness • Functional limitations • Depression • Chronic pain • Increased dependence on others • Epilepsy, CNS d/o, malignancy • focus on effect rather than illness

47. Ideation • Heavily weighted warning sign • Intensity • Persistent of fleeting? • Unrelenting and obtrusive? • Acute or chronic • Formulation of plan?

48. Ideation • Does denial of SI decrease risk? • Only one of many risk factors • Consider in context • Many suicides happen with recent denial of SI • 78% of inpatients who committed suicide either in the hospital of shortly after discharge denied suicidal ideation in their last psychiatric interview prior to suicide. J Clin Psy 2003

49. Ideation • Discrepancy between perceived risk and denial of SI • "You've told that you aren't thinking about suicide and that you don't want to die, but your behavior and what your family says suggests otherwise. It almost seems like you're telling me one thing but thinking another. Help me make sense out of this."

50. Lack of social support • Patient’s perception is key • may not mesh with what you see • Elderly -> family discord • Collateral information • nobody there? red flag