Assessment and Management of Suicide Risk May 24, 2007

1. Assessment and Management of Suicide RiskMay 24, 2007 Melissa J. Pence, Psy.D. Licensed Clinical Psychologist Hampton Roads Neuropsychology and Behavioral Medicine

2. Outline • Impact • Demographics and epidemiology • Etiology • Risk assessment • Psychological Testing • Treatment and prevention • Medical-legal concerns

3. A personal account of the impact of suicide • " His light, through me, will grow as a beacon for others." John C. Gibbs http://www.INeedALighthouse.com/index.html

4. Survivors of Suicide (Schneidman, 1969)

5. Suicide • Definition of suicide: “Suicide is the death resulting directly or indirectly from a positive or negative act of the victim himself, which he knows will produce this result.” Emile Durkheim • Requires: • Death/lethal outcome • Self-inflicted • Intentionally inflicted • Awareness or consciousness of outcome

6. Problems in studying suicide • Low base rate • No test (biological or psychological) or clinical marker that predicts suicide • Requires clinical judgment • Numerous false positives in prediction paradigms • High risk suicidal patients excluded from most clinical studies

7. Demographics and Epidemiology A MAJOR Public Health Problem!

8. How is this data gathered? • Death certificate information reported by each state to the National Center for Health Statistics • Most recent national data available is 2003 • Numbers are generally understood to be a modest underestimation of actual suicide deaths due to difficulties in conclusively determining cause of death

9. U.S. National Statistics (2003) (CDC) • 31,484 deaths by suicide • 86 deaths per day • 1 every 17 minutes • 11th leading cause of death • Approximately 787,000 attempts, ratio 25:1 • Twice as many people die by suicide than by homicide

11. Statistics (2003) (CDC) Number Per Day* Rate % of Deaths Group (Number of Suicides) Rate Nation 31,484 86.3 10.8 1.3 White Male (22,830) 19.5 Males 25,203 69.0 17.6 2.1 White Female (5,655) 4.7 Females 6,281 17.2 4.3 0.5 Nonwhite Male (2,373) 9.1 Whites 28,485 78.0 12.1 1.4 Nonwhite Female (626) 2.2 Nonwhites 2,999 8.2 5.5 0.9 Black Male (1,597) 8.8 Blacks 1,955 5.4 5.1 0.7 Black Female (358) 1.8 Elderly (65+ yrs.) 5,248 14.4 14.6 0.3 Hispanic (2,007) 5.0 Young (15-24 yrs.) 3,988 10.9 9.7 11.9 Native American (322) 10.4 Asian/Pacific Islander (722) 5.5

13. State by State Rate Comparisons

14. Firearms are the Leading Method of Suicide (2003) Suicide Methods: Number Rate Percent of Total Number Rate Percent of Total Firearm suicides 16,907 5.8 53.7% All but Firearms 14,577 5.0 46.3% Suffocation/Hanging 6,635 2.3 21.1% Poisoning 5,462 1.9 17.3% Cut/Pierce 571 0.2 1.8% Drowning 339 0.1 1.2%

15. Data on Means of Suicide (2001)

16. Youth Suicide Rates • 3rd leading cause of death in those aged 15-24, behind only accidents and homicide. • 2nd leading cause of death in college students. • 6th leading cause of death in 5-14 year olds. • Ratios of attempts to completions estimated to range between 100:1 to 200:1 • In 2001, firearms were used in 54% of youth suicides.

17. In 1999, 20% of HS students reported seriously considering suicide and 8% attempted. Frequent drug and alcohol abuse was found to be the most common characteristic in young people who attempted suicide (Department of Education) Youth Suicide

18. Youth Statistics (2003) Age Group Number of Suicides Suicide Rate 10-14 yrs 244 1.2 15-19 yrs 1,487 7.3 20-24 yrs 2,501 12.1

19. Suicide in the Elderly • Higher Completion rates (1:4) over age 65. • Medical illness a significant factor in 70% of suicides over age 70. • Most saw a physician within a few months of their death and 1/3 within the previous week. • Rate of suicide is 14.8 per 100,000 when compared to 10.8 per 100,000 in general population.

20. Male Suicide Rates • 8th leading cause of death (2003) • 4 times more likely to die by suicide than females • 60% of suicides involve the use of a firearm • Rates are relatively constant between ages 20-64, but increase sharply after age 65.

21. Female Suicide Rates • Women attempt suicide twice as often as men. Some studies suggest the rate is closer to 3:1. • One woman attempts suicide every 78 seconds in the U.S. • Rates peak between the ages of 45-54 (around time of menopause) and again after age 75.

23. Breakdown by Race • Caucasians are over 2x more likely to complete suicide than African Americans (AA). • AA males comprised 84% of suicide deaths in that racial group. • Firearms predominant method among AAs, regardless of gender. • American Indian and Alaskan native men have the 2nd highest rate of suicide after Caucasians.

25. Etiology

26. THE NEUROBIOLOGY OF SUICIDAL BEHAVIOR

27. Familial and Genetic Factors • There is a transmission of familial and genetic factors that contribute to risk for suicidal behavior. • Major psychiatric illnesses, such as MDD, schizophrenia, and alcoholism have genetic component in etiology.

28. Familial and Genetic Factors • Several studies have found genetic and familial transmission risk is independent of transmission of psychiatric illness. • First degree relatives of individuals (including dizygotic twins) who have completed suicide have more than 2x the risk of the general population. • For monozygotic twins, risk increases to 11x. (Quin, Agenbo, & Mortensen, 2002) • Recent study could not find genetic effect on suicidal ideation. (Farmer et al, 2001)

29. Studies on the Serotonergic System • Difficult area to study, numerous methodological problems. • There is evidence of modest reductions in in brain stem/prefrontal cortex serotonin or its marker 5-HIAA (metabolite). • Lower CSF (cerebral spinal fluid) 5-HIAA levels has been reported by most studies in patients with a history of suicide attempt and a diagnosis of MDD, Schizophrenia, or PD compared to control groups of patients with these diagnoses.

30. Serotonergic system, continued • Low CSF 5-HIAA level predicts higher rate of past and future suicidal acts as well as seriousness of suicidal acts over the lifetime. • PET scans can map serotonin-induced changes in brain activity. • Size of abnormality in anterior cingulate and prefrontal cortex is proportional to lethality. (Oquendo et al., 2003)

31. Noradrenergic System • Reduced noradrenergic functioning is suggested, however the evidence is not as strong as in the serotonergic system. • The conclusion: there is a period of noradrenergic over-activity (which may be a stress response and state dependent) prior to suicide which contributes to NE depletion.

32. The Diathesis- Stress Model • Proposed by Zubin and Spring (1977) • An individual has unique biological, psychological and social elements. These elements include strengths and vulnerabilities for dealing with stress.

33. The Diathesis-Stress Model

34. Beck’s Cognitive Model (1967) • Schema: tacit beliefs and memory structures that serve to organize the encoding, retrieving, and processing of information • Latent much of the time • May be activated by specific life events • Develop from an early age • Reinforced and consolidated by life events Schema of depressed individuals thought to be rigid, negativistic toward self and others, future is bleak, lack control over outcomes.

35. Beck’s Cognitive Model, Continued • Cognitive distortions most frequently associated with suicidal ideation: • Cognitive constriction or tunnel vision • Polarized or all or nothing thinking • Selective recall of past failure and overlooking past success These are believed to play a role in development and maintenance of dysfunctional attitudes and irrational beliefs.

36. CONDUCTING A SUICIDE RISK ASSESSMENT

37. What is a Suicide Risk Assessment? • “Refers to the establishment of a clinical judgment of risk in the very near future, based on the weighing of a very large mass of available clinical detail.” • “More than a guess or intuition- it is a reasoned, inductive proceess.” • “A necessary exercise in estimating probability over short periods.” From Jacobs, 2003

38. Who should receive a suicide assessment? • ANY patient who meets criteria for DSM-IV mental or substance use disorder(s). • Should initially occur at the point of entry into treatment (i.e. initial visit or intake) and periodically as clinically indicated. • If the patient meets criteria for a depressive disorder and/or manifests any degree of suicide lethality, they should be assessed each session.

39. Two Components of Assessment PART 1: The elicitation and elaboration of suicidal ideation PART 2: The identification and qualification of risk factors for completed suicide

40. Part 1: Assessing Suicidal Ideation • Begin with general questions about self-harm, such as asking whether the patient has had thoughts of death or suicide. Ask them to elaborate in their own words and describe what these thoughts are like. Use open ended questions. • Thoughts should be characterized as active (“When I am walking, I get the impulse to jump out into traffic”) or passive (“Everyone would be better of if I was dead”).

41. Assessing Suicidal Ideation, Continued • If suicidal thoughts are present, assess how often and in what context they occur. • Are they fleeting, periodic, or persistent? Are the situation specific? Are they increasing or decreasing in intensity?

42. Assessing Suicidal Ideation, Continued • The patient should be asked if they have a plan, or if they have thought of a means in which they would use to carry out suicide. • Method (availability, lethality) • Suicide notes, final acts in preparation for death (i.e. will preparation) • Has mental rehearsal taken place? Is there a plan for a time or place? • Have any attempts been made thus far?

43. Assessing Suicidal Ideation, Continued • History of similar thoughts, impulses, plans, aborted attempts and/or attempts should be obtained. • Corroborating report from family or providers should be obtained (if possible).

44. Assessing Suicidal Ideation, Continued • Confidentiality can legally be broken to obtain appropriate care if you have evidence to suggest the patient is acutely a danger to himself or others. • Usually necessary information can be obtained by simply listening to the family members and it may not be necessary to reveal private or confidential information to the family. • However, in some situations you may be obligated to break confidentiality to protect the patient. Remain sensitive to family issues and disclose necessary information to protect the patient. • Helps to discuss this during informed consent at the beginning of the process.

45. Assessing Suicidal Ideation, Continued • Determine if there are any barriers to suicide. • What are the patient’s reasons for living and reasons for dying? • How has the patient managed to evade the act of suicide thus far? • Assess level of current supports (family, significant other, friends, employer, therapist, etc.)

46. Part 2: Assessing Risk Factors

47. “Risk Factor” Defined • Leading to or being associated with suicide • Individuals possessing the risk factor are at greater potential for suicidal behavior • Some risk factors can be changed or reduced (i.e. providing Lithium treatment for Bipolar Disorder), others are static (The patient’s father completed suicide) • From Suicide Prevention Resource Center, www.sprc.org

48. Presence of a mental disorder • Present in over 90% of completed suicides. • High risk diagnoses are: • Depression (unipolar and bipolar) • Alcohol/substance abuse or dependence • Schizophrenia • Borderline Personality Disorder

49. Co-morbidity increases risk! • Psychological autopsy studies of 229 suicides: • 44% had 2 or more Axis I diagnoses • 31% had Axis I and Axis II diagnoses • 50% had Axis I and at least one Axis III diagnosis • 12% had an Axis I diagnosis with no co-morbidity From Henriksson et al, 1993

50. Recent psychiatric hospitalization • Within the last year • Acute exacerbation of illness