Assessing Suicide Risk

1. Assessing Suicide Risk Jennifer Warner, MA, NCC Resources for Human Development

2. Welcome and Introductions

3. Demographics and Statistics “After cancer and heart disease, suicide accounts for more years of life lost than any other cause of death.”* *Understanding suicide facts and figures; http://www.afsp.org

4. Suicide Rates Nationally

6. Suicide was the tenth leading cause of death overall in the United States, claiming the lives of more than 44,000 people. • Suicide was the third leading cause of death among individuals between the ages of 10 and 14, and the second leading cause of death among individuals between the ages of 15 and 34. • There were more than twice as many suicides (44,193) in the United States as there were homicides (17,793). • Centers for Disease Control and Prevention (CDC), 2015

7. More people die annually by suicide than by automobile accidents. • The annual suicide rate in the United States has been increasing over the past decade. • Now, a majority of the suicides by Americans occurred among both men and women between the ages of 45 and 54.* *SAMHSA.gov

9. Every day, approximately 105 Americans die by suicide.* • There is 1 suicide for every estimated 25 attempts.* • There is 1 suicide for every estimated 4 suicide attempts in the elderly.* *CDC – Center for Disease Control, WHO - World Health Organization, AAS – American Association of Suicidology, NAMI- National Alliance on Mental Illness, NIMH – National Institute of Mental Health, SMH – Screening for Mental Health

10. Suicide rates in Pennsylvania

11. Number of deaths due to intentional self-harm per 100,000 population.

12. Pennsylvania is currently ranked 13th in the nation with an average of 13.26 deaths per 100,000 residents annually. (An increase from 12.0 in 2013)* • This number ranks Pennsylvania with Iowa, Michigan, and Wisconsin. *http://www.americashealthrankings.org/PA/Suicide

13. Understanding Suicidality

14. Suicidality • Suicidal ideation and suicide-related behaviors including completed suicide.

15. What is Ideation vs. Plan vs. Intent? • Suicidal Ideation – Any self-reported thoughts of engaging in suicide-related behavior. • Suicidal Plan – An individual or personalized strategy inclusive of time frame and means to complete suicide. • Suicidal Intent – The aim, purpose, or goal of self-killing as one’s purpose.

16. Suicide-related behaviors include: • Completed suicide: self-inflicted behavior with intention to die • Suicidal attempts: self-inflicted potentially harmful behavior without fatal issue but with intention to die • Self-harm: deliberate self-inflicted and potentially harmful acts regardless of motive

17. What Factors Contribute to Suicide Risk?

18. Age • Mental Health and/or Substance Use Disorders • Family history • Trauma (physical, emotional, mental, psychological) • Biopsychosocial factors (Family, Medical, Bullying, etc.) • Prior attempts • Impulsivity

19. Age • Suicide risk increases rapidly during adolescence and young adulthood and stabilizes in early midlife • Greatest risk for suicide attempts is in adolescence and early adulthood • Females tend to have more frequent suicide attempts but males tend to outnumber females in completed suicide (14.2 in males and 12.0 in females per 100,000) between 15-24 year olds

20. Mental Health vs. Drug and Alcohol Issues • Most people who die by suicide have an undiagnosed, untreated, or undertreated mental health and/or substance use disorder. • 30 – 70% of suicide victims suffer from Major Depression or Bipolar Disorder.

21. 2-15% of persons who have been diagnosed with major depression die by suicide.* • An estimated 3-20% of persons who have been diagnosed with Bipolar Disorder die by suicide.* • An estimated 6-15% of persons diagnosed with Schizophrenia die by suicide.* *http://depts.washington.edu/mhreport/facts_suicide.php

22. Suicide is the leading cause of premature death in those diagnosed with Schizophrenia and between 75-95% of those individuals are male.

23. Individuals with Personality Disorders are approximately three times as likely to die by suicide than those without. • 25 – 50% of these individuals also have a substance use or Major Depressive disorder.* *http://depts.washington.edu/mhreport/facts_suicide.php

24. Substance abuse is another factor in suicide and may account for over half of all cases reported.* • About 20% of suicides involve people with alcohol problems. • The lifetime rate of suicide among people with alcohol-use disorders is at least 3-4 times the average.* *http://www.mentalhealthamerica.net/suicide

25. Completed suicides are more likely to be men over 45 who have experienced depression or alcohol abuse. • Alcohol and drug abuse are second only to depression and other mood disorders as the most frequent risk factors for suicide.* • Those with substance abuse disorders are six times more likely to complete suicide than those without. *http://www.samhsa.gov/suicide-prevention

26. The rate of completed suicide among men with substance abuse issues is 2-3 times higher than among those without.* • Women with substance abuse issues are at 6-9 times higher risk of suicide compared to women who do not have issues.* *http://www.mentalhealthamerica.net/suicide

27. Family History • Family history of suicide can contribute to a person’s vulnerability or resiliency to suicide. • Research has shown that the risk for suicide can be inherited (Juel-Nielsen & Videbech, 1970; Roy, et al., 1991; Lester, 2002). • Identical twins have been found to have a higher correlation for suicide than fraternal twins • Exposure to completed and attempted suicide in the family has also been found to increase suicide risk among family members

28. Trauma Trauma can result from any of the following: • Disasters (fires, earthquakes, floods, hurricanes, etc.) • Victimization and severe psychological abuse • Physical assault and/or bodily injury • Surgery • Serious accidents • Exposure to fatalities (homicide, suicide) • Devastating interpersonal losses

29. The effects of trauma may include: • Anxiety • Depression • Hopelessness/despair/helplessness • Anger/hostility • Social isolation • Impulsiveness • Alcohol/Substance abuse • Shame/guilt/lessened self-esteem • Feelings of distrust or feeling threatened • Loss of personal beliefs

30. A significant number of individuals who attempt suicide have a background of some kind of trauma. • It may make those affected feel less connected or that they are a burden to their families and friends. • This may generate feelings of hopelessness and depression which may produce a desire to die.

31. Trauma survivors with an increased risk of suicide include: • Those who self-injure, make non-fatal attempts or frequent threats of suicide • Veterans and members of the military • Physicians • Emergency responders • Sexual assault survivors • Individuals with a brain injury • Physically/developmentally disabled persons

32. Biopsychosocial Factors • Brain studies of people who have died by suicide have shown a number of visible differences compared to those who died from other causes (Mann & Currier, 2012). • Suicide Contagion – the imitative behavior of suicide. Media coverage of suicide is connected to the increase, or decrease, in subsequent suicides, particularly among adolescents (Sisask & Varnik, 2012). • Internet is also a concern due to its worldwide reach and ability to communicate information about notorious and celebrity suicides.

33. Medical Conditions and Pain • Individuals with serious medical conditions such as cancer, HIV, Lupus, and traumatic brain injury may be at an increased risk for suicide. • Chronic pain, insomnia, and adverse reactions to medications may also be contributing factors.

34. Bullying Most likely to precipitate suicidal thinking and suicide attempts in youth who are already depressed, or who have prolonged involvement as both victims and bullies.

35. Prior Attempts • 20% of people who die by suicide have had a prior attempt. • Suicide risk increases during the days/weeks following a hospitalization for a suicide attempt. • 7-10% of individuals who have at least 1 attempted suicide previously die by suicide within the next decade

36. Impulsivity • Impulsivity is highlighted for its role in facilitating suicidal actions in those individuals with suicidal ideation. • Impulsivity may make individuals more likely to act on suicidal feelings. • Impulsivity may also be more of a significant indicator of suicide attempt than the presence of a specific suicidal plan.

37. Impulsivity has been adopted as a risk factor and warning sign for suicide. • The amount of suicide attempts estimated to be impulsive has ranged from a low of 20% to a high of 85%. • Impulsivity can be both a chronic and acute suicide risk.

38. Assessing Suicide Risk in the Mental Health/Substance Abuse Population

39. Assessing Suicide • “Suicidal Assessments should be conducted at first contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical change; for inpatients, prior to increasing privileges and at discharge.”* *Substance Abuse and Mental Health Services Administration SAFE-T guidelines; http://www.samhsa.gov

40. What do I do if I think someone may be suicidal? 1. Ask • Ask the person directly if he/she is having suicidal thoughts/ideas, a plan to act on those thoughts/ideas, and has access to ANY lethal means.

41. You should ask questions like: • “Are you thinking about killing yourself?” • “Have you ever tried to hurt yourself before?” • “Do you think you may try to hurt yourself today?” • “Have you thought about ways in which to hurt yourself?” • “Do you have access to any pills, substances, or anything which may be considered a weapon?”

42. Listen and Look • Listen and look for red flags for suicidal behavior by identifying risk factors present and/or using one of the following mnemonic devices:

43. IS PATH WARM? • Ideation – Either threatened or communicated • Substance abuse – Excessive or increased • Purposelessness – No reason(s) for living • Anxiety – Agitation/Insomnia • Trapped – Feeling there is no way out • Hopelessness • Withdrawing – From friends, family, society • Anger (uncontrolled) – Rage, seeking revenge • Recklessness – Risky acts, unthinking, not processing cause/effect • Mood changes – (dramatic)

44. SAFE-T • Suicide Assessment Five-step Evaluation Tool • Draws upon the American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors.

45. SAFE-T • Identify risk factors • Identify protective factors 3. Conduct suicide inquiry (Explore thoughts, plans, behavior(s), and/or intent 4. Determine risk level/intervention 5. DOCUMENT!!! (Assessment of risk, rationale, intervention, and follow-up)

46. SAFE-T Risk Factors • Suicidal behavior (prior attempts, aborted attempts, or self-injury) • Current or past psychiatric disorders • Key symptoms: anhedonia, impulsivity, hopelessness, anxiety, insomnia, command hallucinations • Family history • Stressors • Change in treatment (new therapist or program) • Access to firearms

47. SAFE-T Protective factors • Internal: ability to cope with stress, religious beliefs, frustration tolerance • External: Responsibility to children or beloved pets, positive therapeutic relationships, social supports

48. SAFE-T Suicide Inquiry • This is a specific line of questioning about thoughts, plans, behaviors, or intent • The clinician wants to address the following: • Ideation: Frequency, intensity, duration in last 48 hours, past month, worst ever • Plan: timing, location, lethality, availability, preparatory acts • Behaviors: past/aborted attempts, rehearsals, non-suicidal self-injurious actions • Intent: extent to which the individual: • 1. Expects to carry out the plan and • 2. believes the plan/act to be lethal vs. self-injurious

49. SAFE-T Risk Level/Intervention • Assessment of risk level is based on clinical judgment after completing SAFE-T Steps 1-3 • Reassess as client or environmental circumstances change.* *http://www.integration.samhsa.gov/images/res/SAFE_T.pdf

50. SAFE-T Risk Levels