Suicide Risk Management for Primary Care

1. Suicide Risk Management for Primary Care Dr Louisa Walker Walker Psychology & Consulting

2. The QPR Chain of Survival(Think CPR) 4 links… Early recognition of warning signs Early application of QPR Early referral to professional care Early assessment and treatment Knowledge + Practice = Action

3. Question: When to ask and what to say Persuade: Influence another to seek help Refer: Help another to get to a professional for assessment Training: On-line or Face-to-face

4. QPR Training Options • Gatekeeper – Foundational Training • Advanced – Suicide Risk Management and Triage • Available online or face-to-face • Tailored for populations – organizations • Primary Care • In Patient Hospital and ED • NGOs – Social Service Agencies • Adolescent MH – Youth Suicide Risk • Maori and Pacific – Whanau Ora • Schools – secondary and tertiary • Law Enforcement – NZ Police, Corrections, Probation • Professional Groups, e.g. Attorneys

5. The Scope of the Problem 522 deaths (2010 – MOH Suicide Facts) Rate: 11.5 per 100,000/year 10 New Zealanders each week (4 commercial jet crashes every year) More than one New Zealander every day

6. New Zealand Data 2010 • Of the 522 deaths • 2.7 x male completions to female • 2 x females to male attempts • Total Maori rate (13 per 100,000) 23 per cent higher than non-Maori • Among OECD NZ sits in the middle of the range • Rates are just ahead of the US and Canada

7. Youth Suicide Rates 2010 • Current youth suicide rate - at 18 per 100,000 • More than a quarter of all youth deaths (15-24yo) are from suicide • Suicide is the second leading cause of death for youth • More teens and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia and influenza, and chronic lung disease, COMBINED.

8. Youth Suicide Rates 2009 • Maori male youth suicide rate – highest in the OECD • 28.7 per 100,000 population • 80% higher than non-Maori youth • Female youth suicide is fifth highest in OECD – behind Korea, Japan, Finland and Switzerland

9. Suicide Attempts Those who die account for a small number of those affected by suicidal behavior… Youth: 100 - 200 attempts per 1 completion Females 15-19yo had highest rate of hospitalization for intentional self-harm

10. Suicide Attempts Elder: 4 attempts per 1 completion Adults over 60 after a non-fatal attempt at most risk that next attempt will be fatal

11. Suicide Attempts 2009 60 percent of all self-harm hospitalisation data has been excluded - due to inconsistencies in the way DHBs report data. Data exclude patients who were only seen in an emergency department and those who were discharged within two days. (???)

12. Survivors of Suicide People who knew someone who died of suicide in the past year: 1.6 x more likely to have suicidal ideation 2.9 x more likely to have made suicidal plans 3.7 x more likely to have made a suicide attempt (Crosby and Sacks 2002)

13. Youth Survivors of Suicide Six months after exposure to suicide youth are: At increased psychiatric risk 4 x more likely to develop a psychiatric disorder 6 x more likely to develop a major depression Youth who knew someone who died by suicide were 3 x more likely to die by suicide than teenage peers who did not know someone who died by suicide

14. Suicide as a Public Health Problem in Primary Care Tetanus is rare, serious, preventable Screen, tetanus shots Suicidal ideation/behavior more common 3 – 8.4% of ED visitors for other reasons also report suicidal ideation

15. Acceptable Failure Rate? The Perfect Depression Care Initiative Dept of Psychiatry – Henry Ford Health System Goal: No suicides Debate: If zero is not the right number of suicides, then what is? One? Four? Forty?

16. Acceptable Failure Rate? Programme resulted in 75% reduction in suicides Results sustained over four years Programme now prototype for redesign of outpatient mental health care

17. Suicide Risk Factors in Primary Care • Medical illnesses contribute to suicidal behavior in several ways: by precipitating a severe depression making an existing psychiatric illness worse, impairing judgment. • Between 25% and 70% of completed suicides were physically ill at the time of death, with physical illness believed to be a major contributing factor in some 11% to 51% of the cases.

18. Chronic Conditions • High rates of depression are reported for patients with: • Diabetes • CVD • COPD • Chronic pain • Cancer, • Lupus, • Rheumatoid arthritis Henk, Katzelnick, Kobak, Griest and Jefferson, 1996

19. Suicide Risk Factors in Primary Care • 80% of the time, people experiencing a first psychiatric illness see a general physician, not a mental health professional. • It has been estimated that between 25% and 30% of all ambulatory patients in general medicine have a diagnosable psychiatric condition. • Suicidal thoughts and feelings are one of the most common complications of untreated psychiatric illness. In general, psychiatric illness increases the risk of suicide 10 fold.

20. Suicide Risk Factors in Primary Care • Untreated depression has been found in 60% of suicides worldwide. • Suicide occurs only rarely in the physically ill where a psychiatric illness is not also present.

21. Depression in Primary Care Multiple studies reveal increased rates of depression in medical populations. In patients with some chronic illnesses, prevalence rates are between 25% and 50%. (Nesse and Finlayson, 1996) Patients with chronic illnesses have been found to be at elevated risk for suicidal behaviours. (Hughes & Kleepsies, 2001).

22. General Neurobiology of Suicide • Reduced serotonin function: • Particularly suicides of high lethality or with considerable planning • Common clinical pathway for suicidal thinking, feeling and behaviours: • Depletion essential neurotransmitters • Dopamine • Serotonin

23. The Depressed Brain • Not functioning within normal limits • Diminished capacity for complex decision-making • Seriously impaired • Strategic thinking • Problem-solving • General executive function • More workdays lost to depression than back pain • Leading cause of absenteeism, poor performance and decreased productivity

25. Alcohol Abuse and Suicide Highest co-occurring diagnosis in completed suicides: Alcohol addiction and MDD Suicide risk for alcoholics equal to risk of MDD Treatment significantly reduces suicide attempts

26. Suicide Risk in Primary Care • Physicians detect only one in six patients who go on to kill themselves, yet warning signs of suicide crisis are known by others (family members, friends, co-workers, etc.). • One study of suicide risk detection found the odds of being asked if you were having thoughts of suicide by a GP was one in 20 (these were patients who made a suicide attempt within 60 days of their visit).

27. What Happens When You Don’t Ask • No query - suicide ideation, current planning or history? “There’s no help here, they can’t even talk about it.” • Or failure to reassess? “They know I’m suicidal but don’t really care.”

28. The Training Gap! Multiple surveys of practicing clinicians found most lacked comprehensive suicide assessment training in graduate and professional programmes “On-the-job training” results in lack of coherence in approaches to assessment and risk management Most lack training in a multi-factor ecological model of suicide risk Risk assessment mistakenly believed to be achieved by a summation of risk factors!

29. Barriers to Suicide Assessment Time (lack of – real or perceived) Attitude Stigma Privacy (lack of) Discomfort

30. Don’t Ask, Don’t Tell Failure to screen amounts to risk denial or risk blindness. Suicide screening questions are direct questions that, if asked correctly, should lead to disclosure of suicidal thoughts, feelings, intent, and desire. Further questioning will establish capacity to inflict self injury.

31. Suicidal Communication As people become suicidal they also may become less self-disclosing about their suicidal thoughts and feelings, and also become less able to ask for help. Yakunina,et al, 2010 The idea that if a patient is suicidal, "they will tell you" is no longer a safe clinical assumption.

32. Self-disclosure and suicide risk:Why not “tell all?” Fear that full disclosure will lead to voluntary or even involuntary hospitalization Fear that full disclosure of suicidal desire and intent will lead to humiliation and/or rejection. Fear that the interviewer is neither benevolent nor trustworthy

33. Suicidal Communications • Suicidal people send warning signs to people in their existing social network of relationships • Failure to respond to suicidal communications may accentuate a crisis

34. Steven Pinker – The Stuff of Thought • The need for indirect speech – the speaker says something he/she doesn’t mean literally knowing the hearer will interpret what was intended and correctly interpret what was meant.

35. Steven Pinker – The Stuff of Thought All humans know how to “read between the lines” See, Politeness Theory (Politeness: Some Universals in Language Use – Brown & Levinson, 1987) Context is everything….

36. Which of the following is a suicide warning sign? Suicide warning signs require understanding the context in which they are observed • “I’m going to blow my brains out.” • “I just can’t stand it anymore.” • If either is a suicide warning sign, which statement requires immediate and urgent intervention?

37. Content vs. Context • “I’m going to blow my brains out!” Is sitting in your office in a psychiatric hospital • “I just can’t stand it anymore.” Is standing well out of arm’s reach on the edge of 10-story building Now… which person needed immediate and aggressive intervention?

38. Indirect Suicidal Communications • Problem gambler caller: “I know it’s too late for me, but can you recommend a counselor for my wife?” • Crisis line caller: “Is 24 aspirins and a bottle of vodka lethal?” • Older woman: “I can’t take care of my two cats anymore, and where I’m going they can’t come. Could you tell me where the nearest animal shelter is?” • Teenager: “Everyone would be better off if I wasn’t around.”

39. Our Job? • To make hearers of suicidal communications, polite requests for rescue or for help understood so that positive actions can follow.

40. The road to suicide is festooned with warning signs… Practice/rehearsal with means (habituating to pain) Verbal (written) threats & “dire warnings” Non-fatal attempts/risky behavior/suspicions injuries 3rd party fear-for-safety reports

41. Clues and Warning Signs • What people say • Direct suicidal communications • Indirect suicidal communications • What people do • Behaviours indicating distress • Mood changes from baseline (increased anger, isolation, flat or depressed affect) • What people endure • Situational stressors • Significant loss • Unwanted change in circumstances • Loss of freedom or independence

42. Official suicide warning signs Consensus and literature based: • Suicide threats • Seeking access to means • Verbal or written statement revealing desire to die • Increased alcohol or drug use • No sense of purpose in life • Feeling trapped with no way out • Withdrawing from friends and family • Giving away prized possessions

43. Suicidal Desire • No reason for living • No wish to carry on • Passive suicide attempts • Not eating • Not taking needed meds • Wishing to make a suicide attempt • Feeling trapped or hopeless • Feeling intolerably alone - Beck et al., 1997; Joiner et al., 1997, 2003

44. Suicidal Desire Outward expression of suicidal desire includes: • Thinking about suicide • Experiencing serious psychological pain • Feeling hopelessness • Feeling helplessness • Feeling like a burden on others • Feeling trapped with no way out • Feeling intolerably alone

45. Suicidal Capability • Capacity for self-injury • Preparing for attempt • Practicing behaviours at sub-lethal level • Via repeated exposure to self-inflicted injury or vicarious experience of painful injury, suicide capable people develop a kind fearlessness about dying by suicide. - Tomas Joiner (2005)

46. Suicidal Capability Suicidal capability is characterized by the following factors: • History of suicide attempts • History of/current violence to others Exposure to/impacted by someone else’s death by suicide

47. Suicidal Capability • Available means of killing self/others • Current intoxication and frequent intoxication • Acute symptoms of mental illness, e.g. dramatic mood change or psychotic symptoms • Extreme agitation/rage, e.g. increased anxiety and/or decreased sleep

48. Acquired Capacity for Self-Harm

49. Journey to SuicideAcquired Capacity for Self-Injury • Lethality of method and seriousness of intent increase with attempts. • Those with a history of suicide attempt have higher pain tolerance than others.

50. Acquired Capacity for Self-Injury People who have experienced or witnessed violence or injury have higher rates of suicide – prostitutes, self-injecting drug abusers, people living in high-crime areas, veterans, physicians.