Suicide Risk Assessment

1. Suicide Risk Assessment A Brief Introduction for Helpers Updated 19-09-13

2. Contacts SERENE.ME.UK/HELPERS #SERENITYPROGRAM SERENITY.PROGRAMME serene.me.uk/helpers/#SERENITYPROGRAMfacebook.com/serenity.programme This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.

3. 18 September 2013 Global economic crisis 'linked to suicide rise' Researchers from the universities of Oxford and Bristol in the UK, along with colleagues from Hong Kong University, used data from the World Health Organization mortality database, the Centers for Disease Control and Prevention and the International Monetary Fund's World Economic Outlook database. In 2009, there was a 37% rise in unemployment and 3% falls in GDP per capita, reflecting the onset of the economic crisis in 2008. There were nearly 5,000 'extra' suicides above the expected level for that year. The financial crisis "almost certainly" led to an increase in suicides across Europe, health experts say. The analysis by US and UK researchers found a rise in suicides was recorded among working age people from 2007 to 2009 in nine of the 10 nations studied. The increases varied between 5% and 17% for under 65s after a period of falling suicide rates, The Lancet reported.

4. 2 May 2013 Suicides soar among US middle-aged people The suicide rate among middle-aged Americans rose 28% in a decade, a new report from the Centers for Disease Control (CDC) has found. Since 2009, suicide has claimed more Americans than motor vehicle crashes. There were 38,350 suicides in 2010, making it the nation's 10th leading cause of death, the CDC said.

5. 7 September 2013 Suicides cost Japan economy $32bn The government in Japan says suicides and depression cost its economy almost 2.7tn yen ($32bn; £21bn) last year. The figures refer to lost incomes and the cost of treatment. It is the first time Japan has released such figures. Japan has one of the world's highest suicide rates, with more than 32,000 people killing themselves last year. PM Naoto Kan sees it as proof of an economic and emotional downturn. In a country in which stoicism and consensus are highly valued, many older people in particular view mental illness as a stigma that can be overcome simply by trying harder, they say. The use of psychotherapy to treat depression has lagged behind North America and Europe, with Japanese doctors often viewing medication as the sole answer, they add.

6. 18 September 2013 One in three 'behind on rent' since housing benefit changes One in three council tenants affected by a recent cut to housing benefit has fallen behind on rent since the policy took effect, figures suggest. The TUC's False Economy campaign made Freedom of Information requests to all of Britain's councils; 114 responded. Data revealed 50,000 tenants had fallen into arrears since 1 April 2013 when the housing benefit changes came in - a move critics called the bedroom tax. The council with the greatest percentage of tenants who had fallen behind was Barrow in north-west England. Of the 289 tenants there affected by the cut, 219 have not been able to pay rent since the policy came into effect. The National Housing Federation has also carried out a survey looking at the numbers of tenants in arrears. It found that a quarter of households affected by the cut have fallen behind in their rent for the first time ever - 11,000 out of 44,000 households were in arrears according to data given by 38 of England's housing associations.

7. Introduction • This is not meant to be a detailed guide to the specialised area of suicide prevention or suicide risk assessment • This presentation provides an introduction to the subject of recognising and intervening safely with clients who may present a risk of suicide • It is intended for volunteer helpers to support their work with the Serenity Programme™

8. Contents • Recognising depression • Typical thought and speech patterns of people at risk of suicide • A semi-structured interview for risk assessment (Meichenbaum) • Factors associated with suicide risk • Risk and protective factors • The ‘PALS’ assessment • Additional resources – SBQ-R, Pierce, PHQ-9 etc.

9. Depression prevalence • Depression is the fourth leading cause of disability and disease worldwide • It is estimated that depression will become the second most common cause of disability, after heart disease, by 2020 • Unipolar forms of depression are more common in women than men. In Britain 3-4% of men and 7-8% of women are thought to suffer from moderate to severe depression at any one time • The incidence of dysthymia (sub-threshold depressive symptoms persisting for more than 2 years) increases with age; 2.5–5% of people will experience dysthymia during their lifetime (Waraich et al, 2004)

10. Types of depression • Major depressive disorder – diagnosed by the person feeling 5 or more of the symptoms of depression, lasting over 2 weeks • Adjustment disorder – milder and shorter-lived forms of depression, often resulting from stressful experiences • Dysthymia – long-term symptoms of depression (of at least 2 years) which are not severe enough to meet criteria for major depression • Post-natal depression – occurs after childbirth (also peri-natal depression, which can occur during pregnancy but which is less common) • Seasonal Affective Disorder (SAD) – depression associated with lack of daylight and shorter daylight hours in winter • Bipolar disorder (sometimes called manic depression)

11. Recognising depression (1 of 2) • Symptoms of depression can appear over a period of months or years or in the case of bipolar disorder, suddenly and escalate over just a few days • In diagnostic terms, 5 of the following should be present during the same 2-week period and have caused a change from previous functioning • For a major depressive episode, symptomsmust appearon a daily basis and last most, or all of theday

12. Recognising depression (2 of 2) • Depressed mood (sad, hopeless or empty) • Markedly diminished pleasure in all (or almost all) activities • Insomnia or hypersomnia • Increase or decrease in appetite or significant weight loss • Fatigue or loss of energy • Feelings of worthlessness • Excessive or unwarranted guilt • Diminished ability to think, concentrate or take decisions • Recurrent thoughts of death, suicidal ideation, having a suicide plan or making a suicide attempt

13. Antidepressants • Antidepressants can be very effective in helping people recover from depression but can also be used to attempt suicide through overdose. There is no clear evidence to show that they reduce suicide or self harm • Selective Serotonin Reuptake Inhibitors (SSRI) are thought to cause suicidal thoughts and behaviour in some people. Current research suggests that this is true for children and adolescents but there is currently no evidence to support the heightened suicide risk in adults • There may be a period of increased risk if motivation to act improves before mood

14. Suicide risk • For people with severe depression, the lifetime risk of suicide may be as high as 6%, compared with a risk of 1.3% in the general population • For those with bipolar disorder, suicide risk is 15 times that of the general population

15. Suicide risk assessment • Is, in itself, treatment • Takes place in an empathic, therapeutic relationship • Is unique for each individual • Is complex and challenging • Is an ongoing process • Errs on the side of caution • Is collaborative and relies on effective communication • Relies on clinical judgement • Takes all threats, warning signs, and risk factors seriously • Asks the ‘tough questions’ • Tries to uncover the underlying message • Is carried out in a culturally-sensitive manner • Is well documented Adapted from Meichenbaum, D.

16. Thinking patterns (1 of 2) • Dichotomous (either-or) thinking • Cognitive rigidity and constriction • Perfectionistic standards toward self and others with high levels of self-criticism • Lack of specificity in autobiographical memory, overgeneral and vague memory interferes with problem-solving because past cannot be used as references for coping in the present • Low confidence in problem-solving ability • ‘Looming vulnerability’ - the perceived experience of negative occurrences as rapidly escalating, quickly approaching adversities that generate distress

17. Thinking patterns (2 of 2) • Hopelessness and helplessness with negative expectations about the future • Ruminative process – feeling cornered, unable to consider alternatives • Present-oriented and view death in a relatively favourable light • Difficulty generating reasons for living • Absence of protective factors such as attraction to life, repulsion by death, surviving and coping beliefs, sense of personal self-efficacy, moral and religious objections to suicide, fear of self-injury and sense of responsibility to family

18. Characteristic speech content (1 of 3) ‘I can't stand being so depressed anymore’ ‘I am damaged goods’ (Intractable emotional pain) ‘Suicide is the only choice I have left’ (Only one or two choices – dichotomous thinking) ‘My family would be better off without me’ ‘I am worthless. They would be better off if I were dead’ ‘I am worth more dead than alive’ (Perception of being a burden on others) ‘I am useless and unwanted’ (Feel unattached, perceive others as uncaring and unsupportive; feel socially disconnected and lack emotional intimacy) ‘No one cares whether I live or die’ (Feel rejected, marginalised, worthless, unlovable, isolated, alone, a failure) ‘I am worthless and don’t deserve to live’ (Guilt and shame) ‘I am a bad person, I have to escape’ (Escape from self)

19. Characteristic speech content (2 of 3) ‘I feel I am crashing, like a freight train or like a wave has hit me. There is no hope. What’s the point?’ (suicidal individuals are prone to produce elaborate mental scenarios anticipating rapidly rising risk with multiply increasing threats. Tend to exaggerate the time course of perceived catastrophic outcomes and have an increased sense of urgency for escape and avoidance) ‘I hate myself’ (Suicidal individuals have an over-generalised memory and tend to selectively recall negative events that contribute to self-loathing) ‘I can’t fix it, I should just die’ (Tunnel vision, inflexibility in generating alternatives, feeling trapped and perceived inescapability)

20. Characteristic speech content (3 of 3) ‘I would rather die than feel like this forever’ (Low distress tolerance and inability to consider future possibility of change) ‘I have lost everything important to me’ ‘My life is empty’ ‘Life is not worth living’ ‘Nothing will change’ ‘What’s the point?’ ‘My life has no purpose’ (Helplessness, hopelessness and meaninglessness) ‘I have screwed up, so I might as well screw up all the way’ (‘when in a hole – keep digging’) ‘They’ll be sorry’ ‘They will miss me when I’m gone’ (post-mortem revenge)

21. Very High Risk Seek immediate professional help High Risk Seek professional help Lower Risk Monitor for development of warning signs Adapted from Rudd et al, 2006

22. What would you do if … • A client calls you on the telephone saying they are going to kill themselves … • What would you want to know? • Work first individually, then as a group …

23. ‘Risk’ & ‘Protective’ Factors Relationships Hope Faith Work Loss Depression Hopelessness Impulsivity ‘Protective’ factors may not mean just the presence of something – it may also mean the absence of something – for example, the absence of access to means of suicide

24. Factors associated with risk (1 of 3) Direct indices of imminent risk for suicide or parasuicide … • Suicide ideation • Suicide threats • Suicide planning and or preparation • Parasuicide in last 12 months Adapted from ‘A social-Behavioral Analysis of Suicide and parasuicide: Implications for Clinical Assessment and Treatment’ by M.M. Linehan (1981), in H. Glaezer & J.F. Clarkin (eds.), Depression: Behavioral and Directive Intervention Strategies. New York: Garland

25. Factors associated with risk (2 of 3) Indirect indices of imminent risk for suicide or parasuicide … • Client falls into suicide or parasuicide risk populations • Recent disruption of loss of relationship • Negative environmental change in last month • Recent hospital discharge • Indifference to, or dissatisfaction with therapy • Current hopelessness, anger or both • Recent medical care • Indirect references to own death, arrangements for death • Abrupt clinical change, either negative or positive

26. Factors associated with risk (3 of 3) Circumstances associated withsuicide or parasuicide in next several hours or days … • Depressive turmoil, severe anxiety, panic attacks, severe mood cycling • Alcohol or drug use • Suicide note written or in progress • Availability of methods • Isolation • Precautions against discovery or intervention, deception or concealment about timing, place etc.

27. PALS - Proximity to others ‘P’ = Proximity to Others • How isolated is the client? Are there any significant others around who might be potential rescuers and interfere or otherwise foil the client’s plan? • Can others be encouraged to actively defuse the client’s plan - e.g. hide guns or confiscate pills? • Clients with few significant relationships are at higher risk

28. PALS - Proximity to others Which plan below is mostlikely to be foiled by others? • A. I am going to go into the girls toilets at school and take an overdose • B. I am going to wait till my parents have left for work and then go into the basement and slash my wrists • C. I am going to go to my boyfriend's house during his birthday party and hang myself in his backyard

29. PALS - Proximity to others Which plan below is mostlikely to be foiled by others? • A. I am going to go into the girls toilets at school and take an overdose (possible answer – toilets are public places) • B. I am going to wait till my parents have left for work and then go into the basement and slash my wrists • C. I am going to go to my boyfriend's house during his birthday party and hang myself in his backyard (very high likelihood of intervention by others)

30. PALS - Availability of means ‘A’ = How accessible is weapon or means of self harm? • Does the client have a gun, knife, pills etc. in his or her possession? • Do they have to steal, borrow or purchase them? • How easily can means of self harm be obtained? • Means of self harm already in client’s possession are most risky

31. PALS - Availability of means Which of the means below is mostaccessible? • A. I have got a large carving knife stashed in the back of my bottom drawer • B. I am going to get my psychiatrist to write me a large prescription for barbiturates • C. I am going to go out on the street and find a drug dealer who will sell me a large dose of heroin

32. PALS - Availability of means Which of the means below is mostaccessible? • A. I have got a large carving knife stashed in the back of my bottom drawer (readily available nearby) • B. I am going to get my psychiatrist to write me a large prescription for barbiturates • C. I am going to go out on the street and find a drug dealer who will sell me a large dose of heroin (Both ‘B’ & ‘C’ rely on the cooperation of others to obtain the means)

33. PALS - Lethality of means ‘L’ = Lethality of Means • How precipitous is the method of self harm? Once started can the method be reversed? • Guns, jumping from great heights and jumping in front of moving vehicles are highly lethal • Cutting and overdoses may be relatively less lethal because people might be able to can change their minds … • Precipitous methods in a plan are more serious and more lethal

34. PALS - Lethality of means Which of the means below is least likely to be harmful? • A. I am going to get my husband's loaded revolver and blow my brains out • B. I am going to jump off a the bridge over the A55at 5 o’clock • C. I am going to take a whole bottle of antibiotics left over from my last urinary track infection

35. PALS - Lethality of means Which of the means below is least likely to be harmful? • A. I am going to get my husband's loaded revolver and blow my brains out (very precipitous and lethal) • B. I am going to jump off a the bridge over the A55at 5 o’clock (highly lethal) • C. I am going to take a whole bottle of antibiotics left over from my last urinary track infection (antibiotics are not usually lethal in overdose)

36. PALS - Specificity of plan ‘S’ = Specificity of Plan • How detailed is the client’s plan? • Have they thought of a place, time or deadline for the act? • Have they made special arrangements to make the plan work?

37. PALS - Specificity of plan Which plan below is most specific and therefore most risky? • A. I am going to hurt myself so my partner will appreciate me more • B. I am going to drive my father's new car off a bridge on my parent's anniversary next week! • C. I am going to get a prescription of pills and take them when no one is around

38. PALS - Specificity of plan Which plan below is most specific and therefore most risky? • A. I am going to hurt myself so my partner will appreciate me more” (neither method, time nor place specified) • B. I am going to drive my father's new car off a bridge on my parent's anniversary next week” (method, time and deadline specified) • C. I am going to get a prescription of pills and take them when no one is around” (what kind of drug, how will they get it and when will it be taken?)

39. Care … • PALS Scale is not predictive when PSYCHOSIS and / or SUBSTANCE ABUSE are present • Alcohol, drugs and severe mental illness may distort judgement such that the risk of suicide, intentional or otherwise, increases significantly

40. References Glaezer, H. & Clarkin, J.F. (Eds.), Depression: Behavioral and Directive Intervention Strategies. New York: Garland Press. Lalkhen, A. G , McCluskey, A. (2008) Clinical tests: Sensitivity and specificity. Continuing Education in Anaesthesia, Critical Care and Pain 2008(8) p. 221-223. Available from: http://ceaccp.oxfordjournals.org/content/8/6/221.full Accessed on 22-04-12. Meichenbaum, D. 35 Years of working with suicidal patients: Lessons learned. Available from: www.melissainstitute.org/documents/35_Years_Suicidal_Patients.pdf Accessed on 21-04-12 Osman, A., Bagge, C. L., Gutierrez, P. M., Konick, L. C., Kopper, B. A., & Barrios, F. X. (2001). The Suicidal Behaviors Questionnaire-Revised (SBQ-R): Validation with clinical and nonclinical samples. Assessment, 8(4), 443-454. Rudd, M.D., Berman, A.L., Joiner, T.E., Nock, M.K., Silverman, M.M., Mandrusiak, M., Orden, K., & Witte, T. (2006). Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life Threatening Behaviour, 36, 255-62. Samaritans information sheet. Available from: http://www.samaritans.org/pdf/Samaritans-MentalHealthAndSuicide.pdf Accessed on 21-04-12. Waraich, P., Goldner, E.M., Somers, J.M. & Hsu, L. (2004) Prevalence and incidence studies of mood disorders: A systematic review of the literature. Canadian Journal of Psychiatry49(2), 124-138.

41. Thanks for Listening! Questions?

42. Additional material • Additional information follows relevant to scoring the SBQ-R …

43. Sensitivity • The sensitivity of a clinical test refers to it’s ability to correctly identify those with the disease • A test with 100% sensitivity correctly identifies all patients with the disease. A test with 80% sensitivity detects 80% of patients with the disease (true positives) but 20% with the disease remain undetected (false negatives) True positives Sensitivity = [True positives + False negatives]

44. Specificity • The specificity of a test refers to it’s ability to correctly identify people without the disease • A test with 100% specificity correctly identifies all patients without the disease. A test with 80% specificity correctly reports 80% of patients without the disease as test negative (true negatives) but 20% patients without the disease are incorrectly identified as test positive (false positives) True negatives Specificity = [True negatives + False positives]

45. Sensitivity and specificity • A test with a high sensitivity but low specificity results in many disease – free patients being told they have the disease • Although the ideal (unrealistic) situation is for a 100% accurate test, a good alternative is to subject patients who are initially positive to a test with high sensitivity / low specificity to a second test with low sensitivity / high specificity • This way, nearly all the false positives can be correctly identified as disease negative

46. PPV and NPV • The Positive predictive value (PPV) of a test answers the question: ‘How likely is it that this person has the disease given that the test result is positive?’ • The Negative predictive value (NPV) of a test answers the question: ‘How likely is it that this person does not have the disease given that the test result is negative?’

47. Receiver operator characteristics • Receiver operator characteristic curves are a plot of (1−specificity) of a test on the x-axis against its sensitivity on the y-axis for all cut-off values • An identical plot is produced when the false positive rate of a test is shown on the x-axis against the true positive rate on the y-axis • An ideal test is represented by the upper curve in the figure (‘C’). The middle curve represents the characteristics of a test more typically seen in routine clinical use (‘B’) • The area under this curve (AUC) represents the overall accuracy of a test, with a value approaching 1.0 indicating a high sensitivity and specificity • The dotted line on the graph (‘A’) shows the ‘line of zero discrimination’ with an AUC of 0.5 (no better than tossing a coin)

48. Receiver operator characteristic curves Line of zero discrimination (AUC = 0.5) Typical clinical test (AUC = 0.5 – 1.0) Theoretically ‘perfect’ test (AUC = 1.0) Lalkhen, A. G , McCluskey, A. Continuing Education in Anaesthesia, Critical Care and Pain 2008(8) p. 221-223.