Risk Assessment and Management, Part 1: Assessing for Suicidality

Educational Objectives

The goal of this program is to improve the assessment and management of suicidality. After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate myths about management of suicidality from facts.
2. Identify risk factors for suicide.
3. Cite factors that protect individuals from suicide.
4. Explain the association between mental disorders and suicide risk.
5. List effective treatment approaches to suicidality.

Summary

Suicidality risk assessment, risk management, and risk mitigation: risk assessment, management, and mitigation are all equally important; risk assessment — includes, eg, what clinician considers, how to find suicidal risk, how to rate it, how to make sure the individual is at the right level of care; risk management — includes how to manage suicidality acutely; risk mitigation — includes steps taken for the patient; giving equal practice and care to everyone is recommended rather than to practice defensively; in some cases it is recommended to document defensively; using this practice, records being perused by legal nonmedical professionals read in such a way that indicates nothing successful will come from any litigation

Myth number one about suicide risk assessment: this is the myth thatrisk assessment is easily accomplished; one of the core misassumptions is that individuals answering “yes” to certain questions are at high risk and those answering “no” are at low risk; eg, majority of individuals that die via suicide answer “no” to the question “are you suicidal?”; majority of individuals that answer “yes” do not commit suicide

Reasons for suicidal risk assessment:ethical — clinical professionals have a desire to care for others and do not want individuals to suffer; statutory — National Patient Safety Goal (NPSG) 15a, created by the Joint Commission, addresses the need to detect and treat suicidal ideation in all settings; sentinel event newsletters in 2016 stated there is no such thing as a “typical suicide victim”

Legal reasons: Tarasoff decision — a student stabbed his fellow to death; at a previous therapy meeting, he had disclosed to the therapist he was going to kill the student; the police detained him at the behest of the therapist, but then released him because he “appeared rational”; once this message was given to the therapist, it was decided to destroy the records of that particular conversation and not take any further action; psychiatrists who examined him at the trial confirmed a diagnosis of paranoid schizophrenia; the jury initially convicted him of second-degree murder; but the court reduced the sentence to manslaughter; he was placed in a state psychiatric hospital; the case never came to trial again, and after 5 yr he was released to India; this was controversial and led to one of the first large legal findings surrounding risk assessment in the duty of medical professionals, the Tarasoff decision; it states “when a doctor or therapist in the exercise of his or her professional skill and knowledge determines or should determine that a warning is essential to avert danger, he incurs a legal obligation to give a warning”; it is the “duty to warn” statute; there were concerns over how much confidentiality would be present if a patient were to talk to a mental health professional; Tarasoff II decision — concerns raised about the Tarasoff decision led to this decision, which promoted the “duty to protect”; it stated the inclusion of other steps (eg, changing medications, changing frequency of visits, decision to hospitalize patient) reasonably necessary to protect intended victims; well-meaning mental health practitioners and providers tend to overestimate risk, not underestimate it, likely because of subconscious bias associated with medical-legal outcomes

Research findings

Large study in JAMA Psychiatry (March 2019): this analyzed prediction models for suicide attempts and deaths; unfortunately their accuracy of prediction using these models was ≈0

Study in JAMA Psychiatry (June 2019): this found symptoms of depression, impulsivity, hopelessness, aggressiveness, and irritability to be trajectories of possible suicide; myth number 2 about risk assessment — this is the myth that risk is a dichotomous issue; however, risk is not an “on” or “off” dichotomous issue; some individuals tend to have chronic suicidality that is present all the time with very few attempts; others are clinically stable for years, but then have sporadic weeks of high-acuity, high-intent suicidality; the presence of risk actually can be very fluid and in certain cases risk mitigation becomes important; some aspects and some risk factors are very static, whereas others are very dynamic; the dynamic risk factors should be mitigated

Meta-analysis study in JAMA Psychiatry (2017): this focused on suicide rates upon discharge from psychiatric facilities; 5-day and 30-day marks were found to have significance; the 5-day mark is more significant and more severe than that at 30 days; this risk is even seen long term

Journal of Suicide and Life-threatening Behavior (2017): this study evaluated the risk factors that are proximate to suicide in the context of denied suicide ideation; “yes” or “no” questions were of very little predictive significance

Stanford study: this was conducted on 5000 patients and discussed sleep variability as a warning sign of suicidal impulse (SI); insomnia and nightmares were found to be predictors of SI

American Journal of Preventive Medicine (2017): this was a very large powered study that assessed 2600 individuals that had killed themselves compared with >250,000 controls over a 14-yr span; there were ≥17 separate health conditions that all noted an increased risk for suicide, even if the patient's answer to suicidal ideations was in the negative; more indications showed an increased rate; conditions included type 2 diabetes, congestive heart failure, coronary artery disease, rheumatoid arthritis, and fibromyalgia

Journal of Clinical Psychiatry (2017): this study looked at the 48 hr prior to a suicide attempt and found alcohol and sedatives showed an increased risk in the 24 hr before an attempt; other drugs, eg, cocaine, cannabis, amphetamines, did not

JAMA Psychiatry (2019): this large meta-analysis study found that there were some increased odds of future SI and/or suicide attempt (SA) in psychotic patients even when accounting for co-occurring psychopathology

Journal of Adolescent Health (2011): this study found suicidality and depression show significant disparities between sexual minority and heterosexual youth; sexual minority youth were 3 times more likely to report suicidality and engage in suicide attempts

Epidemiology of suicide: suicide is the 10th leading cause of death in the United States over the past 2 yr and second leading cause of death in individuals of 15 to 24 yr of age; two-thirds of individuals with suicidal deaths, visited a doctor in the preceding months; 90% of individuals who commit suicide have a psychiatric diagnosis; for other 10% of individuals, it could be, eg, political statements, immense ego blows, chronic pain, and terminal diagnoses; individuals >60 yr of age are more likely to die via suicide; women attempt suicide 3 times more; men are 4 times more successful because their suicide attempts are of higher lethality (eg, gunshot suicides, driving off a bridge, hangings); use of firearms is the most common method to complete suicides in men and women; hanging ranks second for men (has a very high lethality), ingestions or poisoning ranks second for women (has lower lethality)

Risk factors for suicide: includes male sex, history of suicide attempts, family history, >60 yr of age, white or American Indian, being widowed, divorced, or isolated, having psychiatric illness, access to weapons, active substance use disorders, and thoughts of helplessness, hopelessness, and worthlessness

Protective factors from suicide: include involvement of outpatient resources, sobriety or involvement in substance use treatment for individuals with history of substance use disorders, good insight, good family resources and support, religious background, hope for the future, individuals with children and responsibilities and who do not feel their children would “just be better off if [they] were not around”; suicide contracts or safety contracts are not protective factors

Assessment of suicidality: it is important to find out how a suicidal individual was rescued; ask an open-ended question (this does not allege a lack of seriousness on the patient’s part); the individual the patient reached out to can be a part of future safety planning; the speaker says, eg, “Hello sir [or ma’am], I know this has been a very difficult day for you, but I am happy I get to meet with you today, because given all the things in your life, there were enough thoughts to attempt suicide; how am I so lucky to get to talk to you today?”; discovering the expectation of the patient is also critical; as the patient de-escalates, the speaker asks, eg, “You mentioned that you are feeling suicidal; can you describe that to me, because I know it means different things to different people and I want to know where you are coming from”; not everybody that says they are “suicidal” wants to die; there are other things, eg, wanting to sleep, escape stress, not feel pain; such individuals can be offered rational alternatives; ask how individuals feel upon not completing the suicide attempt; if patients are relieved or ambivalent, this can lead to a certain approach; if individuals feel, eg, “dumb,” for their inability to complete suicide, it may be more concerning than a patient’s well-iterated plan for suicide because it shows that they are depressed and hopeless; future attempts are highly likely, and these individuals will likely investigate and try to educate themselves on ways to be more lethal the next time

Mental disorders and suicide risk: unipolar depression is present in ≈15% of individuals; bipolar disorder is present 10% to 20% of the time; command auditory hallucinations increase risk for suicide attempt; manic episodes increase risk, particularly as the mania resolves; in individuals who suffer from schizophrenia, there are 2 clear peaks for suicide; the first peak is at the initial diagnosis, because individuals are still relatively high functioning; the second peak is when individuals are in the late 50s and early 60s, as more of the negative symptoms of schizophrenia start to show

Symptoms associated with risk for suicide: these include extrapyramidal symptoms, tardive dyskinesia, and akathisia; these can develop into thoughts of suicide; such individuals are attempting to escape discomfort, not to die

Medical and psychological significance of suicide attempt: cases that are high in medical and psychological significance have a higher rate of lethality; in documentation, consider possible subsequent use in litigation; instead of stating, eg, an individual was “acting out”, it is better to state “the attempt had low psychological and low medical significance”; explaining the attempt in terms of medical and psychological significance is more informative and objective

Treatment approaches: best options are lithium, clozapine, selective serotonin reuptake inhibitors (SSRIs), and electroconvulsive therapy (ECT); the challenge with clozapine is tolerability; oral administration of lithium is associated with a high risk for overdose; mitigating risk and educating the individual is very important, given its narrow therapeutic index; dialectical behavior therapy (DBT) and cognitive behavioral therapy are excellent therapies for suicidality; myth number 3 about suicide risk — this is the myth that the best treatment for the suicidal individual is inpatient care; in truth, treatment for suicidality is multifactorial; protective inpatient care is a small portion of treatment; consistent outpatient management helps to mitigate relapsing and remitting of patients

Means safety: this is also termed “means restriction”; 3 core assumptions regarding suicide attempts — 1) periods of acute suicidal distress are brief, they develop quickly, but also dissipate quickly; 2) if a suicide attempt is stopped, additional suicide attempts are unlikely if the crisis is adequately resolved; 3) the strongest predictor of outcome is easy access to lethal means; 25% to 30% of individuals make the final decision to act upon suicidality ≤5 min; 70% of individuals make the decision in <1 hr; addressing the crisis in the moment is very important; getting to the patient and starting treatment as quickly as possible is critical rather than, eg, deferring to management 24 hr later; resolving the crisis can make a difference in the patient’s life and likely mitigate future suicide attempts; “it is not about how badly someone is trying to harm themselves, it is about how they are trying to harm themselves”; from 2000 to 2016 there were almost 320,000 firearm suicides

Public health measures and reduced risk for suicide: previously there were many suicide deaths associated with carbon monoxide; cars were equipped with catalytic converters and suicide risk by carbon monoxide poisoning decreased; pill overdosing was curbed by developing child safety pill bottles; seatbelts and mandatory reporting for certain transmissible infections have been introduced to improve safety; author Malcolm Gladwell recently wrote about the rise in suicides in the United Kingdom in which individuals put their heads in their ovens; at the time “town gas,” which had higher levels of carbon monoxide, was used; this was changed to natural gas, and suicides rates decreased by almost 75%

Readings

Ahmedani BK et al. Major physical health conditions and risk of suicide. Am J Prev Med. 2017; 53:308-315; doi: 10.1016/j.amepre.2017.04.001; Bagge CL, Borges G. Acute substance use as a warning sign for suicide attempts: a case-crossover examination of the 48 Hours prior to a recent suicide attempt. J Clin Psychiatry. 2017; 78:691-696; doi: 10.4088/JCP.15m10541; Belsher BE et al. Prediction models for suicide attempts and deaths: a systematic review and simulation. JAMA Psychiatry. 2019; 76:642–651; doi: 10.1001/jamapsychiatry.2019.0174; Berman AL. Risk factors proximate to suicide and suicide risk assessment in the context of denied suicide ideation. Suicide Life Threat Behav. 2018; 48:340-352; doi: 10.1111/sltb.12351; Bernert RA et al. Objectively assessed sleep variability as an acute warning sign of suicidal ideation in a longitudinal evaluation of young adults at high suicide risk. J Clin Psychiatry. 2017; 78:e678-e687; doi: 10.4088/JCP.16m11193; Bryan CJ et al. Patterns of change in suicide ideation signal the recurrence of suicide attempts among high-risk psychiatric outpatients. Behaviour Research and Therapy. 2019; 120:103392; doi: 10.1016/j.brat.2019.04.001; Chung DT et al. Suicide rates after discharge from psychiatric facilities: a systematic review and meta-analysis. JAMA Psychiatry. 2017;74:694–702; doi: 10.1001/jamapsychiatry.2017.1044; D'Anci KE et al. Treatments for the prevention and management of suicide: a systematic review. Ann Intern Med. 2019;171:334; doi: 10.7326/M19-0869 10; Harkavy-Friedman JM et al. Suicide attempts in schizophrenia: the role of command auditory hallucinations for suicide. J Clin Psychiatry. 2003;64:871-874; Hawton K. Restricting access to methods of suicide: rationale and evaluation of this approach to suicide prevention. Crisis. 2007;28:4-9; doi: 10.1027/0227-5910.28.S1.4; Lester D, Walker RL. Hopelessness, helplessness, and haplessness as predictors of suicidal ideation. OMEGA - Journal of Death and Dying. 2007;55:321-324; doi: 10.2190/OM.55.4.f; Marshal MP et al. Suicidality and depression disparities between sexual minority and heterosexual youth: a meta-analytic review. J Adolesc Health. 2011;49:115-123; doi: 10.1016/j.jadohealth.2011.02.005; Melhem NM et al. Severity and variability of depression symptoms predicting suicide attempt in high-risk individuals. JAMA Psychiatry. 2019;76:603-613; doi: 10.1001/jamapsychiatry.2018.4513; Murray D. Is it time to abandon suicide risk assessment? BJPsych Open. 2016;2:e1-e2; doi: 10.1192/bjpo.bp.115.002071; Romero MP, Wintemute GJ. The epidemiology of firearm suicide in the United States. J Urban Health. 2002;79:39–48; doi: 10.1093/jurban/79.1.39; Steele IH et al. Understanding suicide across the lifespan: a United States perspective of suicide risk factors, assessment & management. J Forensic Sci. 2018;63:162-171; doi: 10.1111/1556-4029.13519; Yates K et al. Association of psychotic experiences with subsequent risk of suicidal ideation, suicide attempts, and suicide deaths: a systematic review and meta-analysis of longitudinal population studies. JAMA Psychiatry. 2019;76:180-189; doi: 10.1001/jamapsychiatry.2018.3514.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Thrasher was recorded exclusively for Audio Digest using virtual teleconference software, in compliance with social distancing guidelines during the COVID-19 pandemic. Audio Digest thanks Dr. Thrasher for his cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Lecture ID:

PS502001

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.