Suicidality & Violence

Presented by: Mark C. Stoddart, DHSc(c), MBA, RPA-C Assistant Professor PAP528 Summer 2011

Suicidality & Violence The Challenge:

Prediction

of either in a population vs.

Prediction of either in the individual

Why is prediction of suicide in the individual so difficult?

There are at least four (4) key reasons for this:

1) Low base rates make observation difficult. 2) Suicide is determined by multiple factors which vary across populations and individuals. 3) Suicide risk varies over time within the life of the individual. 4) Predictors of suicide attempts overlap with predictors of suicide.

Very Important!!!
Previous

attempters are at the highest risk for death by suicide.

Definition of Suicide Attempt

any behavior that is dangerous to self,

and

accompanied by the intent to die.

Epidemiology of Suicide Attempts

U.S.

rates: 200 to 600 /100,000 per year Clinical characteristics:

current psychiatric disorder comorbid substance abuse condition current chronic or life-threatening medical disorder in a small minority - no psychiatric disorder but acute emotional reaction to a recent life stressor

More on Suicide Attempts

Take

all attempts seriously.

Suicide Attempts of Low Lethality

Superficial

cutting, burning, swallowing

objects Sometimes motive is external & obvious (ie- avoiding prison) Some pats. describe these acts as means to relieve tension/anxiety (w/o intent to die). Psychotic pats. may occasionally use such behaviors in attempt to maintain contact w/ reality (pain / wound - from real world - distracts
from internal psychotic preoccupations)

Suicide Attempts of Low Lethality

Motives

may be difficult to discern reliably. Self-destructive acts should always be taken seriously.

Is suicide always associated with psychiatric disorder?

in

90 to 95 percent of cases, disorder on Axis I or II (II: Persy d/o, MR) is present the above (i.e.- in the other 5 to 10 percent) it is associated with acute crisis or medical illness

absent

What predicts suicide in a primary care population?

Mood disorder, substance abuse, psychosis, History of suicide attempt prior history of a suicide attempt weighs more heavily than any other factor Moderators of risk situational (life events, chronic stressors) demographic (age, gender, income, etc.)

Demographic and Psychosocial Characteristics of Suicide

Long-term (chronic) background features: prior attempt male living alone limited social contacts lack of dependents financial hardship Short-term (acute) situational stressors: interpersonal loss or conflict other stressful events

Clinical/Psychiatric Risk Factors Long-term (Chronic)

history of suicide attempt history of major depression or bipolar disorder history of alcohol or drug abuse schizophrenia/schizoaffective disorder personality disorder family history of suicide

history of aggressive (externalizing) behavior

pattern of impulsive behavior

Clinical/Psychiatric Risk Factors Short-term (Acute)

current depression current substance abuse or impulsive overuse acute psychic distress (including anxiety, panic) extreme humiliation / disgrace hopelessness demoralization desperation / sense of no way out inability to conceive of alternate solutions break-down in communication / loss of contact with significant other (including therapist)

General Medical Risk Factors:

Cancer Epilepsy Multiple Sclerosis Head injury Cardiovascular disease Dementia

AIDS Cushings Syndrome Klinefelters Syndrome

(47; XXY)

Hemodialysis Prostatic hypertrophy

Fundamentals in the Assessment of Suicidal Behavior

Screening of Long-term Risk: History of suicide attempt and its context History of high risk indicators Assessment of Acute Risk: Current clinical state Current suicidal ideation and planning Attitudes toward suicide Context similar to prior suicide attempts

Interview Guidelines for *Communicating with Patient* at Acute Risk for Suicide
Be

attentive Acknowledge & validate suicidal feelings Remain calm and non-threatened Give patient time to vent Stress a team approach (you and I) Say suicide without flinching

Primary Care/Emergency Medicine Screening for Suicidal Behavior

Step 1. Assess current acute risk
Current depression or demoralization? Current suicidal ideation? Planning? Means? History of suicide attempt(s)? When? Under what circumstances? Are those circumstances present now? If yes, and there is current suicidal ideation, then arrange for immediate emergency psychiatric referral psychiatric inpatient service.

Primary Care/Emergency Medicine Screening for Suicidal Behavior

Step 2. Identify long-term risk indicators
History of suicidal behavior? History of depressive disorder? History of alcohol or drug abuse?

Record the specific risk indicators for this individual in the medical chart

Guidelines for Management of Acute/Chronic Risk

Steps 1 & 2: Assessment of acute/chronic risk Step 3: Referral to mental health?

if acute risk - monitor, contain and secure means for safe transfer to psychiatric inpatient service if chronic (non-acute) risk - refer for mental health treatment and schedule follow-up check (by phone or in person) on follow-through

Step 4: Record results in medical chart

Guidelines for Clinical Management of Patient with Current Acute Risk

Intervene to: ensure immediate safety treat acute risk factors (current depression, psychosis or anxiety) remove / minimize availability of means (e.g. remove pills, guns, etc.) treat chronic (long-term) risk factors (e.g. prophylactic / continuation of treatment of depression) enhance protective factors (e.g. engage family)

Important: *SOP
Always

assess for suicidal risk in patients with any mood disorder.

*SOP= standard operating procedure.

Violence
Increasingly

prominent and problematic part of society. Psychiatry limited ability to predict or prevent specific acts of violence.

Violence Clinical Risk Factors

Male

gender Prior h/o violence Prior h/o or current evidence for other types of poor impulse control Psychiatric Dx or acute state - see next slide -

Violence Clinical Risk Factors

Psychiatric Dx or acute state, including: Mania Psychosis Substance-related states:
Intoxication / Withdrawal

Cognitive Impairments:
Delirium / Dementia / Mental Retardation

Personality D/Os (espy those marked w/ chronic

difficulties w/ impulse control): Borderline Persy d/o; Antisocial Persy d/o Depression (if comorbid w/ any of the above)

Management of Violence or Imminent Violence

1st

ensure your safety & (w/in reason) comfort.

Set limits on a threatening situation. Get out of situation if setting limits not possible or effective. Get additional help (staff, security, police) sooner rather than later, if necessary.

Management of Violence or Imminent Violence

Verbal

interventions may help defuse a potentially violent patient. Clinician needs to walk a line between:

Helping pat. feel empowered & understood and Setting limits on unacceptable behavior

Management of Violence or Imminent Violence

To

set limits in a violent or potentially violent situation, these comments may be entirely appropriate: Im not going to be able to help you unless you stop threatening me. I need to ask you to sit down and stop waving your fists in the air.

Suicidality & Violence

Questions?

N.B. Kaplan

& Sadocks Synopsis of Psychiatry, 10th edition, Chapter 34.