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“Suicide and Self Harming Behaviors”

“Suicide and Self Harming Behaviors”

WAPA Tele-presentation Spring Conference

Thursday April 2nd, 2020

1230-1330

Tony Thrasher, D.O., DFAPA

Medical Director – Crisis Services

Milwaukee County Behavioral Health Division

WAPA Tele-presentation Spring Conference

Thursday April 2nd, 2020

1230-1330

Tony Thrasher, D.O., DFAPA

Medical Director – Crisis Services

Milwaukee County Behavioral Health Division

DisclosuresDisclosures

Source of Research Support and Stock Equity – NONE

Speaker’s Bureau – NONE

Publications: pending Oxford Press “Primer on Emergency Psychiatry”

External:

American Association for Emergency Psychiatry (AAEP)

President Elect

Wisconsin Psychiatric Association (WPA)

Milwaukee Chapter President

State Wide WPA/WACEP Task Force (Co-chair)

Medical College of Wisconsin Dept. of Psychiatry

Associate Clinical Professor

Source of Research Support and Stock Equity – NONE

Speaker’s Bureau – NONE

Publications: pending Oxford Press “Primer on Emergency Psychiatry”

External:

American Association for Emergency Psychiatry (AAEP)

President Elect

Wisconsin Psychiatric Association (WPA)

Milwaukee Chapter President

State Wide WPA/WACEP Task Force (Co-chair)

Medical College of Wisconsin Dept. of Psychiatry

Associate Clinical Professor

Contact InformationContact Information

Tony Thrasher, D.O., DFAPA Medical Director Crisis Services Milwaukee County Behavioral Health

Division tony.thrasher@milwaukeecountywi.gov (414) 257-4789

PCS: 414-257-7260 Crisis Line: 414-257-7222

Tony Thrasher, D.O., DFAPA Medical Director Crisis Services Milwaukee County Behavioral Health

Division tony.thrasher@milwaukeecountywi.gov (414) 257-4789

PCS: 414-257-7260 Crisis Line: 414-257-7222

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Goals of this PresentationGoals of this Presentation

1) Risk assessment vs. Violence prediction

2) Process suicide statistics, epidemiology, and research

3) Consider methods of documentation to this subject matter

4) Look at means counseling and other interventions one can do other than psychotropics

5) Questions, discussion, commentary!

1) Risk assessment vs. Violence prediction

2) Process suicide statistics, epidemiology, and research

3) Consider methods of documentation to this subject matter

4) Look at means counseling and other interventions one can do other than psychotropics

5) Questions, discussion, commentary!

Let’s get started……..Let’s get started……..

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Jama Psychiatry, June 2017Jama Psychiatry, June 2017

“Suicide Rates and the Declining Psychiatric Hospital Bed Capacity in US”

In past 15 years………… 22% increase in suicide rate nationally!! **Most concerning increase amongst young persons

Bed availability decreased from 34 per 100,000 residents to 22 beds per 100,000 residents

“Suicide Rates and the Declining Psychiatric Hospital Bed Capacity in US”

In past 15 years………… 22% increase in suicide rate nationally!! **Most concerning increase amongst young persons

Bed availability decreased from 34 per 100,000 residents to 22 beds per 100,000 residents

Risk assessment…..not violence prediction

Risk assessment…..not violence prediction

“Neither petitioner nor the Association suggests that psychiatrists are always wrong with respect to future dangerousness, only most of the time.

Barefoot v. Estelle, U.S. Supreme Court, 1983 -Justice White

“Neither petitioner nor the Association suggests that psychiatrists are always wrong with respect to future dangerousness, only most of the time.

Barefoot v. Estelle, U.S. Supreme Court, 1983 -Justice White

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JAMA Psychiatry – March 2019

JAMA Psychiatry – March 2019

“Prediction Models for Suicide Attempts and Deaths”

Predictive algorithms by Dept. of Defense, VA, and Kaiser Permanente

Findings: Help to accurately CLASSIFY types, BUT….

Accuracy of prediction is NEAR ZERO

Not ready for clinical applications………

“Prediction Models for Suicide Attempts and Deaths”

Predictive algorithms by Dept. of Defense, VA, and Kaiser Permanente

Findings: Help to accurately CLASSIFY types, BUT….

Accuracy of prediction is NEAR ZERO

Not ready for clinical applications………

JAMA Psychiatry June 2019JAMA Psychiatry June 2019

“Severity and Variability of Depressive Symptoms Predicting Suicide Attempt”

Evaluate trajectories of said predictors:

Depression, impulsive, hopelessness, aggression, and irritability

663 cases, diverse population…..from NYC and Pittsburgh

Those identified are the ones ALREADY being assessed by routine psychiatric evaluations : H/o bipolar, unipolar depression, and childhood abuse

“Severity and Variability of Depressive Symptoms Predicting Suicide Attempt”

Evaluate trajectories of said predictors:

Depression, impulsive, hopelessness, aggression, and irritability

663 cases, diverse population…..from NYC and Pittsburgh

Those identified are the ones ALREADY being assessed by routine psychiatric evaluations : H/o bipolar, unipolar depression, and childhood abuse

Risk Assessment OverviewRisk Assessment Overview

Psychiatrists tend to OVERPREDICT violence, whether it be suicide/homicide

It is much easier to predict short term behavior than long term behavior

Think of forecasting tomorrow’s weather vs. the climate for the winter of 2018

Psychiatrists tend to OVERPREDICT violence, whether it be suicide/homicide

It is much easier to predict short term behavior than long term behavior

Think of forecasting tomorrow’s weather vs. the climate for the winter of 2018

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JAMA Psychiatry, 2017JAMA Psychiatry, 2017

“Suicide Rates After Discharge from Psychiatric Facilities” Immediate post discharge period is of high risk

(5d research vs. 30d research)

However, this risk is also seen LONG TERM

Highly suggest ALL groups starting follow up procedures! BHD with Team Connect……….

“Suicide Rates After Discharge from Psychiatric Facilities” Immediate post discharge period is of high risk

(5d research vs. 30d research)

However, this risk is also seen LONG TERM

Highly suggest ALL groups starting follow up procedures! BHD with Team Connect……….

Suicide and Life Threatening Behavior: April 2017

Suicide and Life Threatening Behavior: April 2017

“Risk Factors Proximate to Suicide and Suicide Risk Assessment in the Context of Denied Suicide Ideation.”

Do we need to examine for SI?

Particularly as a “gateway” question for the rest of our assessment?

Findings were that a “yes” or a “no” were of little statistical significance!

“Risk Factors Proximate to Suicide and Suicide Risk Assessment in the Context of Denied Suicide Ideation.”

Do we need to examine for SI?

Particularly as a “gateway” question for the rest of our assessment?

Findings were that a “yes” or a “no” were of little statistical significance!

In actuality……..In actuality……..

Yes/No questions are of little assistance

Presence of SI of little utility?

There are MANY factors going into suicidality that are not always being assessed such as……….

**LET’S TAKE A LOOK AT SOME OF THOSE FACTORS………

Yes/No questions are of little assistance

Presence of SI of little utility?

There are MANY factors going into suicidality that are not always being assessed such as……….

**LET’S TAKE A LOOK AT SOME OF THOSE FACTORS………

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Journal of Clinical Psychiatry, June 2017

Journal of Clinical Psychiatry, June 2017

“Sleep Variability as an Acute Warning Sign of Suicidal Ideation in a Longitudinal Evaluation of Young Adults at High Suicide Risk”

Stanford study with ~5,000 patients

Insomnia and nightmares proved to be some degree of warning for SI

“Sleep Variability as an Acute Warning Sign of Suicidal Ideation in a Longitudinal Evaluation of Young Adults at High Suicide Risk”

Stanford study with ~5,000 patients

Insomnia and nightmares proved to be some degree of warning for SI

American Journal of Preventive Medicine, Sept 17

American Journal of Preventive Medicine, Sept 17 “Major Physical Health Conditions and

Risk of Suicide”

2,600 suicide completers compared against 267,000 controls over 14 years

17 separate health conditions were noted to be increasing risk for suicide

Combinations of these were of even higher risk

“Major Physical Health Conditions and Risk of Suicide”

2,600 suicide completers compared against 267,000 controls over 14 years

17 separate health conditions were noted to be increasing risk for suicide

Combinations of these were of even higher risk

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Journal of Clin. Psychiatry, June 2017

Journal of Clin. Psychiatry, June 2017

“Acute Substance Use as a Warning Sign for Suicide Attempts”

Looking at 48 hours prior to the suicide attempt……..

Alcohol and sedatives DID show an increased risk in the 24 hours surrounding its usage

Other drugs (cocaine, cannabis, and amphetamines did NOT

“Acute Substance Use as a Warning Sign for Suicide Attempts”

Looking at 48 hours prior to the suicide attempt……..

Alcohol and sedatives DID show an increased risk in the 24 hours surrounding its usage

Other drugs (cocaine, cannabis, and amphetamines did NOT

JAMA Psychiatry, Jan 2019JAMA Psychiatry, Jan 2019

“Psychotic Experiences with the Risk of SI, SA, or Deaths from Suicide”

Experiences are VERY prevalent

Meta Analysis of population studies

Odds of future SI, SA, and death from suicide were all markedly increased Even when accounting for co-occurring

psychopathology!

“Psychotic Experiences with the Risk of SI, SA, or Deaths from Suicide”

Experiences are VERY prevalent

Meta Analysis of population studies

Odds of future SI, SA, and death from suicide were all markedly increased Even when accounting for co-occurring

psychopathology!

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Journal Adolescent Health, 2011

Journal Adolescent Health, 2011

“Suicidality and Depression Disparities between Sexual Minority and Heterosexual Youth”

Sexual minority youth were 3X as likely to report suicidality

LGBTQ youth show increased rates of: SIB -Mood disorders -Homelessness

SA, SI -Anxiety disorders -Bullying

“Suicidality and Depression Disparities between Sexual Minority and Heterosexual Youth”

Sexual minority youth were 3X as likely to report suicidality

LGBTQ youth show increased rates of: SIB -Mood disorders -Homelessness

SA, SI -Anxiety disorders -Bullying

British Journal of Psychiatry: February 2016

British Journal of Psychiatry: February 2016

“Is it Time to Abandon Suicide Risk Assessment?”

ALL patients need to be assessed continually, not just those deemed high risk

Suicide determinations not easy, even retroactively Only 65% postulated by research are actually ruled as such by

Medical Examiners**

**People actually STOP helping patients when this designation occurs………..look to hand it off to someone else!!

“Is it Time to Abandon Suicide Risk Assessment?”

ALL patients need to be assessed continually, not just those deemed high risk

Suicide determinations not easy, even retroactively Only 65% postulated by research are actually ruled as such by

Medical Examiners**

**People actually STOP helping patients when this designation occurs………..look to hand it off to someone else!!

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SUICIDESUICIDE

SuicideSuicide

10th leading cause of death in the U.S. 2nd leading cause in those aged 15-24

2/3 of those that commit visit a doctor in the months preceding 90% of patients who commit have a

psychiatric diagnosis (either pre or post dx) Highest rates in those over the age of 60

10th leading cause of death in the U.S. 2nd leading cause in those aged 15-24

2/3 of those that commit visit a doctor in the months preceding 90% of patients who commit have a

psychiatric diagnosis (either pre or post dx) Highest rates in those over the age of 60

Suicide - more statsSuicide - more stats

Females attempt 3X more, but males are successful 4X more

Firearms are the most used for successful suicides in both genders #2 in successful suicides in males is hanging

#2 in successful suicides in females is poisoning

The most failed method is ingestion (I.e. overdose)

Females attempt 3X more, but males are successful 4X more

Firearms are the most used for successful suicides in both genders #2 in successful suicides in males is hanging

#2 in successful suicides in females is poisoning

The most failed method is ingestion (I.e. overdose)

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What are some risk factors for suicide?What are some risk factors

for suicide?

Risk factors for suicideRisk factors for suicide

Male gender HISTORY……THE #1 RISK FACTOR VERY HELPFUL………….IF VERIFIED!

Family History Over the age of 60 White or Native American Widowed, divorced, isolated Presence of psychiatric illness Helplessness, hopelessness, worthlessness Access to weapons AODA intoxication at the time?

Male gender HISTORY……THE #1 RISK FACTOR VERY HELPFUL………….IF VERIFIED!

Family History Over the age of 60 White or Native American Widowed, divorced, isolated Presence of psychiatric illness Helplessness, hopelessness, worthlessness Access to weapons AODA intoxication at the time?

Protective Factors for suicideProtective Factors for suicide

Lack of serious history Outpatient management No active AODA Good insight NOT “CONTRACTING FOR SAFETY”!!!!!!!!!

Family resources/support Religious background HOPE FOR FUTURE Children and responsibilities…… One drawback here is insurance policies

Lack of serious history Outpatient management No active AODA Good insight NOT “CONTRACTING FOR SAFETY”!!!!!!!!!

Family resources/support Religious background HOPE FOR FUTURE Children and responsibilities…… One drawback here is insurance policies

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Clinical Psychiatric News, June 2019

Clinical Psychiatric News, June 2019

“Why We Need Another Article on Suicide Contracts”

The idea of “making sure you’re OK” is a good one but should not replace actual risk assessment

Irony being that every new option is seen as a competitor of those before……..not an improvement upon it!

“Promises of zero suicides by hospitals, academic institutions, and governmental entities are well meaning but possibly misleading……”

“Why We Need Another Article on Suicide Contracts”

The idea of “making sure you’re OK” is a good one but should not replace actual risk assessment

Irony being that every new option is seen as a competitor of those before……..not an improvement upon it!

“Promises of zero suicides by hospitals, academic institutions, and governmental entities are well meaning but possibly misleading……”

What to consider when assessing SI/SA

What to consider when assessing SI/SA

What was the plan? What was the method? How were they rescued? What was the EXPECTATION? To die, to go to sleep, to not feel pain, to escape

stressful situation, etc……

What was the motivation? Escape suffering, manipulation, depression, anger, etc..

How did they feel upon not completing the task? PLEASE DON’T MAKE THIS

BLACK/WHITE

What was the plan? What was the method? How were they rescued? What was the EXPECTATION? To die, to go to sleep, to not feel pain, to escape

stressful situation, etc……

What was the motivation? Escape suffering, manipulation, depression, anger, etc..

How did they feel upon not completing the task? PLEASE DON’T MAKE THIS

BLACK/WHITE

Psychiatric specific risk factorsPsychiatric specific risk factors

Mood Disorders are highest risk 15% for MDD 15% for bipolar

Command hallucinations….specific Akathisia, EPS, TD Manic episode…….as progresses, low sleep Schizophrenia Unlike the mood disorders, the risk for suicide here

is at its highest at the beginning of the illness

Mood Disorders are highest risk 15% for MDD 15% for bipolar

Command hallucinations….specific Akathisia, EPS, TD Manic episode…….as progresses, low sleep Schizophrenia Unlike the mood disorders, the risk for suicide here

is at its highest at the beginning of the illness

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When balancing these factors….

When balancing these factors….

MEDICALLY SIGNIFICANT SUICIDE ATTEMPT

Not always psychologically significant due to a variety of rescue factors

PSYCHOLOGICALLY SIGNIFICANT SUICIDE ATTEMPT

Not always medically significant due to sub-lethal measures

ATTEMPTS CAN BE BOTH CATEGORIES AND THESE ARE OFTEN OF HIGHER PERCENTAGE IN

COMPLETION!

MEDICALLY SIGNIFICANT SUICIDE ATTEMPT

Not always psychologically significant due to a variety of rescue factors

PSYCHOLOGICALLY SIGNIFICANT SUICIDE ATTEMPT

Not always medically significant due to sub-lethal measures

ATTEMPTS CAN BE BOTH CATEGORIES AND THESE ARE OFTEN OF HIGHER PERCENTAGE IN

COMPLETION!

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Treatments for SI?Treatments for SI?

Some meds/treatments have excellent data: Lithium Clozapine ECT SSRIs

Tied into post mortem studies of suicide victims CSF and decreased serotonin metabolites (5-HIAA)

Genetic ties as well…..

DBT in Borderline Personality Disorder CBT in Major Depressive Disorder Does inpatient always treat this? Is it always the

most protective? (5% of all suicides are on inpt)

Some meds/treatments have excellent data: Lithium Clozapine ECT SSRIs

Tied into post mortem studies of suicide victims CSF and decreased serotonin metabolites (5-HIAA)

Genetic ties as well…..

DBT in Borderline Personality Disorder CBT in Major Depressive Disorder Does inpatient always treat this? Is it always the

most protective? (5% of all suicides are on inpt)

Means Safety CounselingMeans Safety Counseling

Trying to limit access to items of high lethality

Three Core Assumptions (Rozek et al) 1) Periods of Acute Suicidal Distress are Brief

2) Additional suicide attempts are unlikely if a crisis is resolved

3) Easy access to lethal means is the STRONGEST predictor of attempt outcome

Trying to limit access to items of high lethality

Three Core Assumptions (Rozek et al) 1) Periods of Acute Suicidal Distress are Brief

2) Additional suicide attempts are unlikely if a crisis is resolved

3) Easy access to lethal means is the STRONGEST predictor of attempt outcome

Means counselingMeans counseling

25-40% made final decision to act within FIVE MINUTES of the attempt

70% made final decision to act within ONE HOUR of the attempt

Hence, IMMEDIATE lethal items are of the highest concern……

25-40% made final decision to act within FIVE MINUTES of the attempt

70% made final decision to act within ONE HOUR of the attempt

Hence, IMMEDIATE lethal items are of the highest concern……

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Means counseling (cont.)Means counseling (cont.)

Suicidal intent has a very weak correlation to the lethality of a suicide attempt

It is more about HOW someone is trying to harm themselves………not HOW badly….

For those that attempt suicide: 90% do NOT go on to commit suicide

75% do NOT make another attempt Owens, Harrack, and House (2002)

Suicidal intent has a very weak correlation to the lethality of a suicide attempt

It is more about HOW someone is trying to harm themselves………not HOW badly….

For those that attempt suicide: 90% do NOT go on to commit suicide

75% do NOT make another attempt Owens, Harrack, and House (2002)

Does this work elsewhere?Does this work elsewhere?

Restriction of means in other countries?

Barbituate restriction in Australia

Pesticide restriction in Sri Lanka

Packaging changes for pain meds in U.K.

TOWN GAS vs. NATURAL GAS (CO levels)

Restriction of means in the US??

Mortality rate of firearms in suicide is 92%

Hanging 78%

Drowning 67%

Ingestions 2%

Restriction of means in other countries?

Barbituate restriction in Australia

Pesticide restriction in Sri Lanka

Packaging changes for pain meds in U.K.

TOWN GAS vs. NATURAL GAS (CO levels)

Restriction of means in the US??

Mortality rate of firearms in suicide is 92%

Hanging 78%

Drowning 67%

Ingestions 2%

CouplingCoupling

Epidemiological approach to suicide increase

Looks at the minimization of high lethality items in one’s environment

Data shows those with SI do not “displace” (i.e., they do not “find another way”) Owens D, Horrocks J, and House A. Fatal and non-fatal repetition of self-harm: systematic review. British

Journal of Psychiatry. 2002;181:193-199.

Instead it is COUPLED

Town gas vs. that of Natural gas in 1960s

Catalytic converters affecting carbon monoxide as well

Opioids and overdose lethality (combined with BZDs)

“Don’t look at the patient……look at the patient’s WORLD”

Epidemiological approach to suicide increase

Looks at the minimization of high lethality items in one’s environment

Data shows those with SI do not “displace” (i.e., they do not “find another way”) Owens D, Horrocks J, and House A. Fatal and non-fatal repetition of self-harm: systematic review. British

Journal of Psychiatry. 2002;181:193-199.

Instead it is COUPLED

Town gas vs. that of Natural gas in 1960s

Catalytic converters affecting carbon monoxide as well

Opioids and overdose lethality (combined with BZDs)

“Don’t look at the patient……look at the patient’s WORLD”

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American Journal of Public Health, 2015

American Journal of Public Health, 2015

From 2001-2010, there were approximately 120,000 gun murders

Less than 5% of the individuals had any history of mental illness (let alone active symptoms)

**The truth is that the mentally ill are much more frequently the victims of violent crime, not the aggressor!

From 2001-2010, there were approximately 120,000 gun murders

Less than 5% of the individuals had any history of mental illness (let alone active symptoms)

**The truth is that the mentally ill are much more frequently the victims of violent crime, not the aggressor!

Gun suicide vs. Gun homicide?Gun suicide vs. Gun homicide?

Suicide is an issue in public health that is TWICE the size of ALL homicides

13.4 vs. 6.1 deaths per 10,000 Injury Prevention and Control: Data and Statistics (WISQARS); CDC, 2018.

When comparing to mass shootings, this number increases exponentially!

Stopping all mass shootings 2000-2016 would:

Save ~500 lives from mass shootings

319,000 suicides during that SAME time period Injury Prevention and Control: Data and Statistics (WISQARS); CDC, 2018.

Hence, if conversations are to involve the MENTALLY ILL and firearm ACCESS, then suicide should be the real public health conversation!

Other causes of mortality decreasing in US, but suicide is up 33% since 2000

Psychiatric Services 2018; 69: 119801199; doi: 10.1176/appi/ps201800365

Suicide is an issue in public health that is TWICE the size of ALL homicides

13.4 vs. 6.1 deaths per 10,000 Injury Prevention and Control: Data and Statistics (WISQARS); CDC, 2018.

When comparing to mass shootings, this number increases exponentially!

Stopping all mass shootings 2000-2016 would:

Save ~500 lives from mass shootings

319,000 suicides during that SAME time period Injury Prevention and Control: Data and Statistics (WISQARS); CDC, 2018.

Hence, if conversations are to involve the MENTALLY ILL and firearm ACCESS, then suicide should be the real public health conversation!

Other causes of mortality decreasing in US, but suicide is up 33% since 2000

Psychiatric Services 2018; 69: 119801199; doi: 10.1176/appi/ps201800365

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Importance of Gun LocksImportance of Gun Locks

Great strategy to mitigate long term risk

Particularly on those patients who have a long cultural history of owning guns in the house legally

It delays impulsive attempts and can help to bring family members in as a supportive source!

Great strategy to mitigate long term risk

Particularly on those patients who have a long cultural history of owning guns in the house legally

It delays impulsive attempts and can help to bring family members in as a supportive source!

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“Having the talk”“Having the talk”

Rozel, Soliman, Abhishek, 2008

The “Gun Talk” is much like the “sex talk” with an adolescent:

Awkward……controversial to some

Extremely important, evidence based, and clinically effective!

Focusing not on absolute SAFE storage……but SAFER storage and therapeutic alliance Great medicolegal documentation option………

Rozel, Soliman, Abhishek, 2008

The “Gun Talk” is much like the “sex talk” with an adolescent:

Awkward……controversial to some

Extremely important, evidence based, and clinically effective!

Focusing not on absolute SAFE storage……but SAFER storage and therapeutic alliance Great medicolegal documentation option………

Can we measure this with a scale??

Can we measure this with a scale??

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Objective scales - Actuarial Instruments

Objective scales - Actuarial Instruments

Because of the over prediction by psychiatrists, there is always a “push” to find objective measures… However, they seemed to rely strongly on

historical elements which will never change….leaving people at sustained high risk Is this person-centered?? Does this allow for

growth and self actualization??

Because of the over prediction by psychiatrists, there is always a “push” to find objective measures… However, they seemed to rely strongly on

historical elements which will never change….leaving people at sustained high risk Is this person-centered?? Does this allow for

growth and self actualization??

Objective Measures – Genetic testing??

Objective Measures – Genetic testing??

American Journal of Psychiatry, August 2019

“GWAS of Suicide Attempt in Psychiatric Disorders in Association with MDD polygenic scores”

Noted that MDD is a strong risk factor for suicide attempts…………

However, no current identifiable genetic labeling or predictive risk

Promising start……but far from clinical application!

American Journal of Psychiatry, August 2019

“GWAS of Suicide Attempt in Psychiatric Disorders in Association with MDD polygenic scores”

Noted that MDD is a strong risk factor for suicide attempts…………

However, no current identifiable genetic labeling or predictive risk

Promising start……but far from clinical application!

Wait………but we use ______!Wait………but we use ______!

Screening instruments are often used in a myriad of settings……

Particularly where mental health staff are not present/easily accessible……….

Remember that finding the “issue” is not medicolegally comparable to treating it!

Screening instruments are often used in a myriad of settings……

Particularly where mental health staff are not present/easily accessible……….

Remember that finding the “issue” is not medicolegally comparable to treating it!

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Provider Risk AssessmentProvider Risk Assessment

4 Domains to look at: 1) Protective Factors

The patient brings this to the assessment

2) Risk Factors The patient also brings this to the assessment

3) Mitigation of Risk / Aftercare Plan This is the treatment that the treatment team provide This is where discharge planning can have the most emphasis

4) Clinical Decision Making This is the summary of the above and the proper notation

thereof!

4 Domains to look at: 1) Protective Factors

The patient brings this to the assessment

2) Risk Factors The patient also brings this to the assessment

3) Mitigation of Risk / Aftercare Plan This is the treatment that the treatment team provide This is where discharge planning can have the most emphasis

4) Clinical Decision Making This is the summary of the above and the proper notation

thereof!

Contingent SuicidalityContingent Suicidality

“If you don’t_____, I’ll kill myself!” “If you _______, I’ll kill myself!” Very minimal risk of actual SA with contingent

suicidality (I.e. threatening) Lambert, UT-SW, 2002………..and 2012 ~150 patients followed for 7 years after SI/SA in ER 1/3 were contingent and NO SUICIDES WERE

SEEN! In the remaining 2/3, there was the expected

epidemiological rate of suicide.

“If you don’t_____, I’ll kill myself!” “If you _______, I’ll kill myself!” Very minimal risk of actual SA with contingent

suicidality (I.e. threatening) Lambert, UT-SW, 2002………..and 2012 ~150 patients followed for 7 years after SI/SA in ER 1/3 were contingent and NO SUICIDES WERE

SEEN! In the remaining 2/3, there was the expected

epidemiological rate of suicide.

MITIGATION OF RISKMITIGATION OF RISK

Avoiding weapons or medications of harm Avoiding AODA and discuss risk factors Referred to appropriate level of care Outpt appointments, follow up phone calls, etc….

Discussed safety plan of how to handle future exacerbations

Consulted with colleagues Treat acute symptoms and arrange for proper med Educated significant others, got collateral

Avoiding weapons or medications of harm Avoiding AODA and discuss risk factors Referred to appropriate level of care Outpt appointments, follow up phone calls, etc….

Discussed safety plan of how to handle future exacerbations

Consulted with colleagues Treat acute symptoms and arrange for proper med Educated significant others, got collateral

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CLINICAL DECISION MAKING

CLINICAL DECISION MAKING

PROTECTIVE FACTORS ARE MORE COMPELLING THAN RISK FACTORS

Patient not at short term risk Patient prefers outpatient treatment Pt declines inpatient and coercive risks outweigh

the benefits Hospitalization might worsen a problem with

dependency History of abuse carries risk of low grade self

harm, and inpatient tx can lead to trauma

PROTECTIVE FACTORS ARE MORE COMPELLING THAN RISK FACTORS

Patient not at short term risk Patient prefers outpatient treatment Pt declines inpatient and coercive risks outweigh

the benefits Hospitalization might worsen a problem with

dependency History of abuse carries risk of low grade self

harm, and inpatient tx can lead to trauma

Carlat Psychiatry Report, Fall 2015

Carlat Psychiatry Report, Fall 2015

“7 Clinical Pearls for Risk Assessment” 1) Sleep Assessment/Treatment

2) Agitation/Anxiety

3) Recent Med Changes of Concern

4) Firearm possession, removal, and mitigation

5) Dynamic stressors (recent) – can we change?

6) Safety planning – rehearsing contingencies

7) Remember that chronic risk may remain, even after acute issue has resolved/lessened

“7 Clinical Pearls for Risk Assessment” 1) Sleep Assessment/Treatment

2) Agitation/Anxiety

3) Recent Med Changes of Concern

4) Firearm possession, removal, and mitigation

5) Dynamic stressors (recent) – can we change?

6) Safety planning – rehearsing contingencies

7) Remember that chronic risk may remain, even after acute issue has resolved/lessened

Chronically self destructiveChronically self destructive

While a patient may always be at long term risk of harm to self, there is not always a clinical indication for inpatient treatment 1) No clear factors for inpatient treatment to

modify 2) This can reinforce maladaptive coping

skills 3) This is often contraindicated due to the

worsening of the patient’s prognosis 4) No acute risk to be modified

While a patient may always be at long term risk of harm to self, there is not always a clinical indication for inpatient treatment 1) No clear factors for inpatient treatment to

modify 2) This can reinforce maladaptive coping

skills 3) This is often contraindicated due to the

worsening of the patient’s prognosis 4) No acute risk to be modified

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Self InjurySelf Injury

“This isn’t suicidality……they are just cutting.”

To be fair, this is a related (yet separate) type of self harm

Can also include burning, insertions, etc……

It is too often seen as a dichotomy (either you do this or you are “truly suicidal”)

It is also too often (improperly) reduced to being part of only one diagnosis (BPD)

The term in of itself can be pejorative, and we’ll go over better wording in a couple of slides!

“This isn’t suicidality……they are just cutting.”

To be fair, this is a related (yet separate) type of self harm

Can also include burning, insertions, etc……

It is too often seen as a dichotomy (either you do this or you are “truly suicidal”)

It is also too often (improperly) reduced to being part of only one diagnosis (BPD)

The term in of itself can be pejorative, and we’ll go over better wording in a couple of slides!

SIB/NSSI ResearchSIB/NSSI Research

Intervening in the first year after self-injurious behavior (SIB) occurs can mitigate risk and possibly reduce further exacerbations…….

J Clin Psychiatry. 2016 Feb;77(2):240-6. doi: 10.4088/JCP.14m09453.

Too often the presence of SIB leads to a reduction in the perceived need for services (conflating to lack of evidence base for inpatient care)…..

JAMA Psychiatry January 2019 Volume 76, Number 1

Research (including Zero Suicide projects) have minimized some of these as end points and/or inclusion subjects………..

JAMA October 23/30, 2018 Volume 320, Number 16

Intervening in the first year after self-injurious behavior (SIB) occurs can mitigate risk and possibly reduce further exacerbations…….

J Clin Psychiatry. 2016 Feb;77(2):240-6. doi: 10.4088/JCP.14m09453.

Too often the presence of SIB leads to a reduction in the perceived need for services (conflating to lack of evidence base for inpatient care)…..

JAMA Psychiatry January 2019 Volume 76, Number 1

Research (including Zero Suicide projects) have minimized some of these as end points and/or inclusion subjects………..

JAMA October 23/30, 2018 Volume 320, Number 16

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Other Suggestions on SIBOther Suggestions on SIB

Start with terminology:

Use either self injurious behavior (SIB) or non-suicidal self injury (NSSI)

When documenting, note that the above can occur in a myriad of diagnoses (MDD, Schizophrenia, etc…….)

Avoid conflating this behavior as automatically inferring “not serious” and/or “not suicidal”

As with any good interview, we should be inquiring “what does this behavior/action help you with?”

The answers may surprise you!

There are evidence based treatments to assist with this behavior (assuming there is some egodystonicity)

Therapies

As well as medications (evidence base on naltrexone)

Start with terminology:

Use either self injurious behavior (SIB) or non-suicidal self injury (NSSI)

When documenting, note that the above can occur in a myriad of diagnoses (MDD, Schizophrenia, etc…….)

Avoid conflating this behavior as automatically inferring “not serious” and/or “not suicidal”

As with any good interview, we should be inquiring “what does this behavior/action help you with?”

The answers may surprise you!

There are evidence based treatments to assist with this behavior (assuming there is some egodystonicity)

Therapies

As well as medications (evidence base on naltrexone)

Outside Legal ThoughtsOutside Legal Thoughts

Susan Stefan and the “Center for Public Representation’s National Emergency Department Project”

1) Mrs. Stefan is a nationally regarded attorney who specializes in litigation against psychiatrists

2) She is immensely helpful in educating professionals on what to watch for…….

- “exaggerated perceptions of liability”-she lectures frequently on the fact that mental health providers focus on the wrong concerns…..

Susan Stefan and the “Center for Public Representation’s National Emergency Department Project”

1) Mrs. Stefan is a nationally regarded attorney who specializes in litigation against psychiatrists

2) She is immensely helpful in educating professionals on what to watch for…….

- “exaggerated perceptions of liability”-she lectures frequently on the fact that mental health providers focus on the wrong concerns…..

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“Exaggerated Perception of Liability”

“Exaggerated Perception of Liability”

Focusing on liability from failure to admit, as opposed to: Poor assessments when admitted (violence on inpt

units) Missing medical issues Neglecting civil issues surrounding forcible treatment

and improper civil commitment Most successful litigation (Stefan 2008) stems from: Not from “not predicting suicide” Errors in much more transparent issues Missing consults, being told issues with

insurance/bed status, not meeting inpt criteria, missing med screens, collateral, et al

Focusing on liability from failure to admit, as opposed to: Poor assessments when admitted (violence on inpt

units) Missing medical issues Neglecting civil issues surrounding forcible treatment

and improper civil commitment Most successful litigation (Stefan 2008) stems from: Not from “not predicting suicide” Errors in much more transparent issues Missing consults, being told issues with

insurance/bed status, not meeting inpt criteria, missing med screens, collateral, et al

CONCLUSIONSCONCLUSIONS

1) We are assessing risk, not predicting violence.

2) Suicide is increasing, and there are risk factors and data we know about the illness.

3) There is also epidemiological data on both causes and possible treatments/further directions

4) There are also interventions and treatments that go beyond psychotropic prescriptions.

1) We are assessing risk, not predicting violence.

2) Suicide is increasing, and there are risk factors and data we know about the illness.

3) There is also epidemiological data on both causes and possible treatments/further directions

4) There are also interventions and treatments that go beyond psychotropic prescriptions.

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CONCLUSIONSCONCLUSIONS

5) Measuring the risk factors and protective factors, while balancing in your interventions, leads to good clinical decision making

6) Self injurious behavior is a separate, yet related item that has data in of itself and should not be conflated.

7) Documentation is integral to not only patient care but also your medicolegal safety!

5) Measuring the risk factors and protective factors, while balancing in your interventions, leads to good clinical decision making

6) Self injurious behavior is a separate, yet related item that has data in of itself and should not be conflated.

7) Documentation is integral to not only patient care but also your medicolegal safety!

“To exist is to change, to change is to mature, to

mature is to go on creating oneself endlessly.”

Henri Bergson

“To exist is to change, to change is to mature, to

mature is to go on creating oneself endlessly.”

Henri Bergson

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