SUICIDAL BEHAVIORS IN CLINICAL HIGH-RISK

POPULATIONSShirley Yen, Ph.D.

Associate ProfessorDepartment of Psychiatry

Beth Israel Deaconess Medical Center, Harvard Medical School

OBJECTIVES

•Review evidence for increased risk of suicidal behavior in those who experience psychosis symptoms.

•Review basics of a suicide risk assessment.•Provide overview of intervention strategies to reduce suicidal behavior, with a specific focus on Safety Planning Intervention.

•Clinical vignettes to illustrate intervention for suicidal behaviors.

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Suicidal Behaviors in Adolescents with Psychosis-like (CHR) Symptoms• In a prospective study of 1112 school aged adolescents in

Ireland, part of the Saving and Empowering Young Lives in Europe (SEYLE) study, 7% of adolescents endorsed psychotic symptoms. (Kellerer et al., 2013; JAMA Psychiatry).

• Those endorsing psychotic symptoms have an estimated 10-fold increased odds of any suicidal behavior.

• Those with comorbid depression have a 14-fold increased odds of suicide plans or acts compared to depressed non-psychotic youths.

• Those with suicidal ideation have a 20-fold increased odds of suicide plans or acts compared to adolescents without psychotic symptoms.

• 70-fold increased odds of an acute suicide attempt.

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Increased Risk of Suicide After FEP• After two years of follow-up, 12.4% attempted suicide

(Sanchez-Gistau et al., 2012).• After four years of follow-up, 18% attempted suicide

and 3% died by suicide (Clarke et al., 2006).• Suicide rate is 11x higher in patients with early

psychosis compared to the general population in the year after initial contact, 7x higher five years later, 4x higher ten years later. Median time to suicide was 5.4 years (Dutta et al., 2010).

• Risk appears to diminish over time, though still elevated compared to general population.

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Diagnostically agnostic• Collaborative Psychiatric Epidemiology Surveys (N = 11,716); (DeVylder et al., 2014 JAMA Psychiatry)• Psychosis symptoms -> higher SI (5x) and SA (9x)

• Most with psychosis (65%) also met criteria for depression, anxiety, or substance use disorder.

• Cohort study in Sweden of hospitalized patients with FEP (N = 2819) (Bjorkenstam et al., 2014 Schizophrenia Res)• Overall, 121 patients (4.3%) died by suicide.• The highest suicide rates were found in depressive disorder with psychotic symptoms and in delusional disorder.

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Hallucinations and Delusions• In the Clinical Antipsychotic Trials of Intervention

Effectiveness (CATIE; N = 1460), positive symptoms of psychosis (hallucinations and delusions) were found to exacerbate the relationship between symptoms of depression and suicide ideation. (Bornheimer et al., 2016)

• In several prospective follow-up studies of early psychosis, patients with hallucinations were at significantly greater risk of attempting suicide (Connell et al, 2016), developing suicidal tendencies (Madsen et al., 2012) and more likely to die by suicide (Upthegrove et al., 2010).

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Suicide is Not Predictable• There are numerous risk factors and warning signs

(please refer to https://afsp.org/about-suicide/risk-factors-and-warning-signs/ as a reference).

• There is no typical suicide victim.• In a study of 4,800 hospitalized vets, it was not possible to

identify who would die by suicide — too many false-negatives, false-positives.

• Individuals of all races, creeds, incomes and educational levels die by suicide. Individuals who engage in suicidal behavior are extremely heterogeneous

American Foundation for Suicide Prevention

Suicide Communications Are Often Not Made to Professionals

• In one psychological autopsy study, only 18% told professionals of intentions (Robins et al., Am J Psychiatry, 1959)

• In a study of suicidal deaths in hospitals:• 77% denied intent on last communication• 28% had “no suicide” contracts with their caregivers

(Busch et al., J Clin Psychiatry, 2003)• Research does not support the use of no-harm contracts

(NHC) as a method of preventing suicide, nor from protecting clinicians from malpractice litigation in the event of a client suicide (Lewis, SLTB 2007)

American Foundation for Suicide Prevention

Suicide Communications ARE Made to Others

• Importance of Gatekeepers, Family, Friends• In adolescents, 50% communicated their intent to family

members (Robins et al., Am J Psychiatry, 1959)• In elderly, 58% communicated their intent to the primary

care doctor (Busch et al., J Clin Psychiatry, 2003)

American Foundation for Suicide Prevention

Gatekeeper Tools

• QPR (Question, Persuade, Refer)• https://qprinstitute.com/

• Suicide Screens• Patient Health Questionnaire (PHQ-9) • Ask Suicide-Screening Questions (ASQ) Toolkit

https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/index.shtml

• Patient Safety Screener 3 (PSS-3) http://www.sprc.org/micro-learning/patientsafetyscreener

• Don’t approach like a checklist; be empathic and genuine.• Be extremely judicious in using hospitalization as a

deterrent.

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Means Restriction

• Many suicide attempts occur with little planning, particularly in young people

• Intent is usually ambivalent:• “I instantly realized that everything in my life that I’d thought

was unfixable was totally fixable – except for having just jumped.” (Golden Gate bridge survivor, New Yorker, 2003)

• Suicide rates much higher in states that have the least gun restriction laws

• Firearms used in suicides by young people usually belong to parents

• Blister packs reduced suicide death by Tylenol by 43% after Britain changed their packaging requirements.

• Reducing means saves lives

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Suicide Death by Method

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Clinician: Suicide Risk Assessments• To gain a more comprehensive understanding:• Columbia Suicide Severity Rating Scale (C-SSRS)

• http://cssrs.columbia.edu/• Suicide Assessment Five-step Evaluation and Triage (SAFE-T):

• https://store.samhsa.gov/product/SAFE-T-Pocket-Card-Suicide-Assessment-Five-Step-Evaluation-and-Triage-for-Clinicians/sma09-4432

• Collaborative Assessment and Management of Suicidality (CAMS)

• https://cams-care.com/about-cams/

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Suicide Risk Assessment Basics• Therapeutic alliance is key. Collaborative, compassionate,

authentic• Ideation: How often do you find yourself thinking about suicide?

How long have you been feeling this way?• Intent: How strong is the urge to suicide? Do you intend to act

on your suicidal thoughts? (If unknown, past history of attempts).

• Plan: Do you have a specific plan? What is your plan? Have you been mentally rehearsing this plan?

• Means: Do you have what you need to carry out your plan? Do you have access to firearms? What about substances? Large quantities of medications?

• Protective Factors: What are some things that have kept you alive? What do you value? What’s important to you?

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Suicide Prevention Interventions• Safety Planning Intervention (SPI)• Dialectical Behavior Therapy (DBT)• Collaborative Assessment and Management of

Suicidality (CAMS)• Coping Long Term with Attempted Suicide (CLASP)

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Safety Planning Intervention (SPI)

• One-session evidence-based intervention• Does not replace any longer-term treatment• 25-45 minutes• Incorporates evidence-based risk reduction strategies:

• teaching brief problem solving and coping skills• enhancing social support and identifying emergency

contacts• means restriction• motivation for additional treatment

Stanley & Brown, Cognitive and Behavioral Practice, 2012Stanley et al., JAMA Psychiatry, 2018

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Clinical Context

• Risk assessment / individual’s story• Rationale for Safety Planning• Creation of Safety Plan• Reasons for Living• Plan for how safety plan will be used• Future visits: review and revise as needed

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Risk Assessment / Individual’s Story• Have the individual feel heard; build alliance with

patient• Understand clinical context• Set up the expectation that this will be a collaborative

process• Listen for information you may then use in the safety

plan

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TIME

RIS

KDanger of acting on suicidal feelings

Rationale for Safety Planning

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Safety Plan Overview: 6 Steps1. Recognizing warning signs2. Using internal coping

strategies that clients can do on their own

3. Using social supports & environment to distract--socializing with people or going to social/public places

4. Contacting family/friends and asking for assistance

5. Contacting mental health professionals/agencies

6. Make the environment safe.

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Step 1: Warning Signs

• Present rationale• Need to know when to use the safety plan

• How will you know that you need to look at your safety plan?• What do you experience right before you begin to think

about suicide? • Get specific

• Command hallucinations (voice telling me to kill myself)• Thoughts or images (traumatic flashback)• Emotions (sad, tearful, angry, down on myself)• Behaviors (increased urge to smoke MJ, poor sleep)• Physical sensations (increased agitation, need to pace)• External cues or events (near X bridge)

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Step 2: Internal Coping Strategies

• Present rationale• People are often alone when they think about suicide• These are things you can do, on your own, to take your

mind off your problems, at least for a little while.

• “What can you do, on your own, to help yourself not act on these thoughts or urges?

• What activities would help you take your mind off your problems, even if for a short while?”

• Get specific.• Assess likelihood of using strategies; prioritize easiest • Make sure the strategy itself is not a problem.

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Step 3: Social Contacts to Distract• Present rationale

• Distract yourself from the negative feelings• Place yourself in a safe environment

• Choose people who will distract you; do not need to disclose feelings

• Choose safe places with others available for distraction• Lounge, library, coffee shop (avoid bars, etc.)

• Be specific. Get names, phone numbers, places. • Assess barriers/likelihood of using strategies

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Step 4: Social contacts for support• Present rationale

• Have someone who can support you, help you, keep you from hurting yourself, make you feel less isolated

• Who are the friends or family members who’ve been supportive in past?

• Can Safety Plan be shared with them?

• Assess barriers/likelihood of using strategies

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Step 5: Professional Support• Present rationale

• Sometimes seeking support from family or friends is not enough, and it’s time to move on to seeking professional support

• Outpatient MH professionals• National Suicide Prevention Lifeline (1-800-273-8255)

(988)• Spanish and Deaf/Hard of hearing options available

• Samaritans (1-800-870-4673)• Crisis Text Line (741-741)• If needed, nearest ED

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Step 6: Create Safety in Environment• Present rationale

• Not necessarily the next step after seeking professional support, but something people can do in the background to promote their own safety

• Goal is to put distance between the individual & the things they can use, or do, to harm themselves

• You’ll know from risk assessment what objects, places, medications, substances, they need to create distance from.

• Assess barriers/likelihood of using strategies• Elicit help from loved ones

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Reasons for Living• Present rationale

• Sometimes when thinking about suicide, it can be helpful to think about those things in your life that keep you moving forward, give you hope for the future, or are otherwise a deterrent to suicide.

• What are your reasons for living?• Can offer: “for some people, it may be a particular family

member, for others it could be for spiritual reasons. Some may identify a purpose or goal that they have not yet achieved…”

• Rather than focus on filling out all blanks, if difficult to generate; better to focus on the strongest RFLs even if few in number

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Final Steps

• Review Safety Plan • What would get in the way of using it? • How will you remember the Safety Plan when in a

crisis? • Where will you keep it? • Is there anyone you would feel comfortable sharing this

with?• They can jump to strategies most helpful in the

moment– doesn’t need to be linear

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Future Clinical Contacts

• Review previous safety plan• Have you used your safety plan? • How did you use it? What steps did you use?• Was it helpful? • Is there anything that is not helpful that we should

change? (Can review each item to make sure still potentially helpful)

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Clinical Case A

• A is a 26 yo White, single, trans-female, college educated and currently unemployed, living with roommates, with financial help from parents.

• No history of suicide attempts but chronic high suicidal ideation with a specific plan which has resulted in 4 hospitalizations.

• Psychosis symptoms: multiple personalities and believed she was possessed by demons, and grandiosity. Symptoms have mostly remitted, though multiple personalities still speak to her.

• Depression and anxiety, high degree of interpersonal sensitivity, diagnosis remains unclear.

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Case A Clinical Context

• Chain analyses with therapist identified triggers and warning signs; however, rejected other aspects of DBT.

• Precursors were generally interpersonal in nature.• Very quickly goes to suicide as a way of problem solving.• Plan involved going to a particular bridge and jumping. Client

goes to the bridge weekly and to contemplate suicide. • Recently faced romantic rejection of someone she relied on

frequently during suicidal crises.• Pattern of engaging with others through suicidality.

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Case A Safety Plan

• Step 1: Noticing urges to walk to bridge; thoughts/feelings of rejection; one of her personalities/voices telling her to kill herself

• Step 2: Playing video role play games, watching Netflix movies

• Step 3: Reaching out to friends X, Y, Z to play multiplayer games including card games, acting games, role play games

• Step 4: Call specific friends or mother• Step 5: Call suicide hotline, therapist, will go to ED• Step 6: Lives with roommates who help client keep a safe

environment.• Reasons for Living: Wants to help others

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Case A Managing non-acute risk• Client keeps safety plan on phone, she and therapist

periodically review and revise.• Use of acceptance and commitment therapy techniques.• Build on her value of wanting to help others and her value of

friendships. Suicide would conflict with those values.• Patient is quite fused with idea of suicide, gradually use

diffusion techniques to label suicidal thoughts and urges as automatic problem-solving strategy that has mostly not been effective (e.g., compromises friendships).

• Diversify activities, diversify ways of engaging with others.

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Clinical Case B

• B is a 24 yo White, single, male, some college, working part-time, has significant other and living at home with parents.

• History of one interrupted attempt and multiple incidents of cutting. Has been hospitalized twice due to increased suicidal ideation.

• Psychosis symptoms: Dx bipolar disorder, hallucinations of voices telling him to kill himself, thought insertion, paranoid thinking, intrusive thoughts of harming others.

• Mood lability and anxiety, poor sleep, substance use. When depressed, has thoughts of how bad his life and of his worthlessness.

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Case B Clinical Context

• Worked with therapist using a DBT-informed model.• Chain analyses revealed that self-deprecating thoughts

secondary to psychiatric symptoms were primary drivers of SI, and this also led to substance use.

• Substance use was an early target of intervention and client managed to be sober with support from AA/NA.

• Had a non-specific plan of overdosing.• Therapist ensured that parents were aware of risk, so

as to make the home environment as safe as possible (including management of medications).

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Case B Safety Plan

• Step 1: Urges to use, thoughts of “my life sucks”, poor sleep

• Step 2: Intense exercise, peaceful walk, breathing exercises

• Step 3: Reaching out to friends X, Y, Z to work out, rock climb

• Step 4: Call parents, AA/NA sponsors, significant other• Step 5: Call suicide hotline, therapist• Step 6: Parents help in maintaining a safe environment• Reasons for Living: Values independence, Significant

other

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Case B Managing non-acute risk• Client keeps safety plan on phone, he and therapist

periodically review and revise.• Track thoughts and urges on DBT diary card and reviews

with therapist.• Many mood and psychosis symptoms and self-

deprecating thoughts remain but these and suicidal thoughts are manageable.

• Responds well to skill-based interventions.• Practice and review of distress tolerance and emotion

regulation skills. • Working towards building “a life worth living”

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Clinical Case C

• C is a 24 yo AA, single, male, obtained GED but could not attend high school or college due to psychiatric (psychosis) symptoms, unemployed and living at home with his mother.

• History of 4 previous attempts and 5+ hospitalizations for suicidal behaviors and disorganized behaviors.

• Psychosis symptoms: Dx paranoid schizophrenia, hallucinations of voices telling him to kill himself, thought insertion, thought blocking, delusions, cognitive disorganization.

• Depression and anxiety, chronic daily SI without a plan

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Case C Clinical Context

• Client was on a number of high dose antipsychotic medications but continued to experience psychotic symptoms daily.

• Mistrustful of therapists due to past experiences of hospitalizations, when he told his therapist about psychotic symptoms. After that, did not see a therapist for 5 years.

• Worked with therapist using a ACT-informed model.• Using ACT videos and metaphors, focused on

accepting his symptoms and identifying values and goals.

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Case C Safety Plan

• Step 1: Urges to stop medications, pacing, agitation, speaking loudly, voices telling him to kill himself

• Step 2: Listening to music loudly on headphones, video games, take a walk

• Step 3: Gaming with others• Step 4: Talk to mother• Step 5: Call suicide hotline, therapist• Step 6: Mother helps maintain a safe environment• Reasons for Living: Mother, dog, goal of becoming a

writer

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Case C Managing non-acute risk• Client keeps safety plan on phone, mother had a copy

that she put in the kitchen, he and therapist periodically review and revise.

• ACT approach resonated with this patient.• Continued to have many symptoms and self-

deprecating thoughts during course of therapy, but found them to be less distressing.

• Staying on his medication• Worked with his mother to get more resources• Working towards taking classes at community college

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Emergency Care Options

• Safety Planning if risk is not imminent.• Emergency department (evaluation for psychiatric

admission)• Resources for the individual:

• National Suicide Prevention Lifeline (800) 273-8255• Samaritans (877) 870-4673• Crisis Text Line “Home” to 741741

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Acknowledgements & Resources • American Foundation for Suicide Prevention (ASFP) for

grant funding and slides https://afsp.org/• Suicide Prevention Resource Center

https://www.sprc.org/• Zero suicide initiative https://zerosuicide.sprc.org/• Colleagues that have contributed to this slide

presentation:• Christopher Ceccolini• Lisa Uebelacker, Ph.D.• Lauren Weinstock, Ph.D.• Michelle West, Ph.D.

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