Objectives Participant will be able to explain the phenomenology and - - PDF document

10/3/2016 1 Assessment & Management

• f Suicide Risk

in a Non‐Psychiatric Setting

Inga Giske, MSN, RN‐BC Nurse Manager Acute Inpatient Psychiatry Providence St. Vincent Medical Center October 15, 2016

Objectives

• Participant will be able to explain the

phenomenology and prevalence of suicide

• Participant will be able to identify risk factors

and warning signs of suicide

• Participant will be able to complete a basic

screening for suicidal thinking and behaviors

• Participant will be able to identify where to

find additional resources on suicide for both clinicians and patients

Terminology/Definitions

• Self‐Directed Violence (SDV)

– Behavior that is self‐directed and deliberately results in injury or the potential for injury to oneself

• Suicide

– Death caused by self‐directed injurious behavior with any intent to die as a result of the behavior

• Suicide Attempt

– A non‐fatal self‐directed potentially injurious behavior with any intent to die as a result of the behavior. – May or may not result in injury

Source: https://www.cdc.gov/violenceprevention/pdf/self‐directed‐violence‐a.pdf

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Self‐Directed Violence Flowchart

Source: https://www.cdc.gov/violenceprevention/pdf/self‐directed‐violence‐a.pdf

Language Matters Unacceptable Terms → Acceptable Terms

• Completed Suicide → Suicide
• Failed Aempt → Suicide Aempt or Suicidal Self‐Directed

Violence

• Nonfatal suicide → Suicide Aempt
• Parasuicide → Non‐Suicidal Self‐Directed Violence or Suicidal

Self‐Directed Violence

• Successful suicide → Suicide
• Suicidality → Suicidal Thoughts and Suicidal Behavior
• Suicide Gesture, Manipulave Act, Suicide Threat → Non‐

Suicidal Self‐Directed Violence or Suicidal Self‐Directed Violence

Source: https://www.cdc.gov/violenceprevention/pdf/self‐directed‐violence‐a.pdf

National Suicide Prevalence Data

• 10th Leading Cause of Death in US

– 42,773 suicides – Rate of 13.4

 Rate calculated (number suicides/population) X 100,000

• 2nd leading COD for age 15‐24
• 1 person suicides every 12.3 minutes
• ~1.1 million adults attempt annually
• 1 suicide attempt every 30 seconds
• 3.4 males die by suicide for every female death by

suicide

• 3 female attempts for every male attempt

Source: http://www.suicidology.org/Portals/14/docs/Resources/FactSheets/2014/2014datapgsv1b.pdf

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Oregon Data

• 8th Leading Cause of Death in 2014

– 782 suicides – Rate of 19.7

 Rate calculated (number suicides/population) X 100,000

• 1 person dies by suicide every 11 hours
• We rank 8th in the Nation
• In 2010 Suicide Cost $740,356,000

– Or, ~$1,080,811 per suicide death

Sources: http://www.suicidology.org/Portals/14/docs/Resources/FactSheets/2014/2014datapgsv1b.pdf Washington County, Oregon Suicide Statistics released September 2016 https://afsp.org/about‐suicide/state‐fact‐sheets/#Oregon

Means Matter

Source: https://afsp.org/about‐suicide/suicide‐statistics/

Impact of Suicide

• For each suicide

– 147 people are exposed (6.3 million annually) – 18 of those people experience a major life disruption

• 750,000 survivors of suicide annually
• Suicide costs the US ~$51 Billion Annually

Sources: http://www.suicidology.org/Portals/14/docs/Resources/FactSheets/2014/2014datapgsv1b.pdf http://www.cdc.gov/violenceprevention/pdf/suicide‐datasheet‐a.PDF

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You Understand the Definitions and the Data

But what is suicide, really?

Suicide – What is it?

• A multi‐factorial event

– Psychiatric Illness & Co‐Morbidity – Neurobiology – Impulsivity – Hopelessness – Family History – Psychodynamics/Psychological Vulnerability – Suicidal Behavior – Life Stressors – Access to Weapons – Severe Medical Illness – Substance Use/Abuse – Personality Disorder/Traits

Myths vs The Facts

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Myth vs Fact

You shouldn’t ask people if they’re thinking about suicide because you might put the idea in their head

• Asking people doesn’t give them the idea.
• Asking does give them the opportunity to share their

mindset and intentions with you.

• Asking can give them hope that you care enough to ask

and give them relief to share their burden.

• Asking can help diffuse some of the tension that is

causing their suicidal thoughts

Source: http://www.suicide.org/suicide‐myths.html

Myth vs Fact

People who are suicidal definitely want to die

• The vast majority of suicidal people do NOT

actually want to die

• They ARE in pain and want to stop the pain
• They typically have a lot of ambivalence

Source: http://www.suicide.org/suicide‐myths.html

Myth vs Fact

People who talk about suicide are trying to manipulate you

• People are in pain and need help
• An assumption of attempted manipulation is

insensitive and ignorant

• Most people who suicide talk about it first
• Always take the talk seriously

Source: http://www.suicide.org/suicide‐myths.html

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Myth vs Fact

People who suicide or attempt suicide are crazy

• No, they are in pain
• They likely have a diagnosable mental disorder

with neurobiological causes which is treatable

• New research is identifying genetic drivers of

suicide

Source: http://www.suicide.org/suicide‐myths.html

Myth vs Fact

People who attempt suicide and survive will not attempt again

• Some people who attempt suicide will

attempt again.

• Past suicide attempts are a known risk factor

for suicide

Source: http://www.suicide.org/suicide‐myths.html

Myth vs Fact

Once a person decides to die by suicide, there is nothing we can do to stop them

• Suicide can be prevented!
• Most people do not necessarily want to die,

they want to end their pain

Source: http://www.suicide.org/suicide‐myths.html

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Myth vs Fact

Suicide always occurs without warning signs

• There are almost always warning signs!

Source: http://www.suicide.org/suicide‐myths.html

Risk Factors

• Serious illness, or physical chronic pain
• Previous suicide attempt
• Hx of non‐suicidal self‐directed violence
• Hx of trauma or loss
• Social isolation or a pattern/hx of aggressive and

antisocial behavior

• Discharge within the past year from a psychiatric

facility (greater risk within the first few weeks/months)

Risk Factors

• Access to lethal means
• Perceived sense of being a burden on family,

loved ones, or society

• Profound sense of hopelessness and shame
• Diagnosis of mental or emotional disorder,

particularly depression or bipolar disorder

• Alcohol and/or drug abuse

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Protective Factors

• Able to identify reason(s) for living
• Responsibility to family or others
• Living with family
• Supportive social network and/or family
• Fear of death or dying due to pain and suffering
• Belief that suicide is immoral and/or high

spirituality

• Engaged in work or school

Warning Signs

• Ideation
• Substance Abuse
• Purposelessness
• Anxiety
• Trapped
• Hopelessness
• Withdrawal
• Anger
• Recklessness
• Mood Changes

Source: http://www.suicidology.org/resources/warning‐signs

Warning Signs of Acute Risk

• Threatening to hurt self or kill self, or talking

about wanting to hurt to kill self

• Looking for ways to kill self, seeking access to

means (firearms, pills, other methods)

• Talking or writing about death, dying, or

suicide, when these actions are out of the

• rdinary

Source: http://www.suicidology.org/resources/warning‐signs

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Expanded Warning Signs

• Increased substance (alcohol or drug) use
• No reason for living; no sense of purpose in life
• Anxiety, agitation, unable to sleep or sleeping all of the

time

• Feeling trapped ‐ like there's no way out
• Hopelessness
• Withdrawal from friends, family and society
• Rage, uncontrolled anger, seeking revenge
• Acting reckless or engaging in risky activities, seemingly

without thinking

• Dramatic mood changes
• Giving away belongings

Source: http://www.suicidology.org/resources/warning‐signs

Suicide Risk Screening Suicide Risk Screening

• SAMHSA recommends two suicide risk

screening tools

– Columbia Suicide Severity Rating Scale (C‐SSRS) – SAFE‐T

Source: http://www.integration.samhsa.gov/clinical‐practice/screening‐tools

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C‐SSRS

Source: http://www.cssrs.columbia.edu/scales_practice_cssrs.html

C‐SSRS Training

• Link to C‐SSRS FREE Screening Training Video

– https://www.youtube.com/watch?v=Ted_gl‐UXi8

SAFE‐T

• Pocket Card available free from SPRC with an

app as well

SAFE‐T Card

• Guides clinicians through five steps which

address the patient's level of suicide risk and suggest appropriate interventions

Source: http://www.integration.samhsa.gov/images/res/SAFE_T.pdf

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You’ve Identified Risk What Now?? With The Patient

• Manage your own reactions

– Stay calm

• Keep talking with the patient

– Find about what’s personally driving their wish to die – Find out what’s keeping them alive – What has worked for them when they’ve felt like this before

• Let them know you will help them get help
• Reinforce that their safety is your priority and you

are there to help the them keep themself safe

Crisis Resources

• National Suicide Prevention Life Line

– 1‐800‐273‐TALK (1‐800‐273‐8255)

• Veteran Option press 1
• Text Crisis Line

– Text START to 741‐741

• Oregon County Map with Mental Health and

Crisis Line Numbers

– https://public.health.oregon.gov/PreventionWellness/ SafeLiving/SuicidePrevention/Pages/cntymap.aspx

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What Not to Do

• Do not have patient Contract for Safety

– Not an evidenced based practice – Does not protect you from liability – Instead: Safety Plan

• Don’t tell them you understand
• Don’t tell them it will be ok

Safety Plan

• Part of a comprehensive suicide support plan
• Prioritized list of coping strategies, supports

and resources to support person in suicidal crisis

– Developed with Patient – Brief and Specific – In patient’s own words – Easy to Read – Portable

Source: http://www.sprc.org/sites/default/files/SafetyPlanningGuide%20Quick%20Guide%20for%20Clinicians.pdf

Safety Plan

• Comprised of:

– Warning Signs (AKA triggers) – Internal Coping Strategies – Social Supports for Distraction – Family/Friends/Supports Who Can Help – Professional Supports – Making Environment Safe

Source: http://www.sprc.org/sites/default/files/SafetyPlanningGuide%20Quick%20Guide%20for%20Clinicians.pdf

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Resources

• American Association of Suicidology: http://www.suicidology.org/
• American Foundation for Suicide Prevention: https://afsp.org/
• CDC: http://www.cdc.gov/ViolencePrevention/suicide/index.html
• Columbia Suicide Severity Rating Scale: http://cssrs.columbia.edu/index.html
• Crisis Text Line: Text START to 741‐741 http://www.crisistextline.org/
• National Suicide Prevention Lifeline: 1‐800‐273‐8255 online chat available

http://www.cdc.gov/ViolencePrevention/suicide/index.html

• NIMH Suicide Prevention: https://www.nimh.nih.gov/health/topics/suicide‐

prevention/index.shtml

• SAMHSA – Mental Health Screening Tools:

http://www.integration.samhsa.gov/clinical‐practice/screening‐tools#suicide

• Suicide Prevention Resource Center: http://www.sprc.org/
• Teen Help http://www.teenhelp.org/
• Veterans Affairs Suicide Prevention:

http://www.mentalhealth.va.gov/suicide_prevention/

• Veterans Crisis Line: 1‐800‐273‐8255 Press 1 https://www.veteranscrisisline.net/

References

Billings, C. V. (2003). Psychiatric inpatient suicide: Risk factors and risk predictors. Journal of the American Psychiatric Nurses Association, 105‐106. Columbia Suicide Severity Rating Scale. (n.d.). Retrieved September 30, 2016, from http://www.cssrs.columbia.edu/scales_practice_cssrs.html Crosby, A. E., MD, MPH, Ortega, L., MD, MPH, & Melanson, C., MPH. (2011). Self‐directed Violence Surveillance: Uniform Definitions and Recommended Data Elements. Atlanta, GA: Centers for Disease Control and Prevention. Drapeau, C. M., MA, & McIntosh, J. L., Ph.D. (2015, December 22). USA Suicide: 2014 Official Final Data. Retrieved September 24, 2016, from http://www.suicidology.org/Portals/14/docs/Resources/FactSheets/2014/2014datapgsv1b.pdf Ellis, T. E., Green, K. L., Allen, J. G., Jobes, D. A., & Nadorff, M. R. (2012, March). Collaborative Assessment and Management of Suicidality in an Inpatient Setting: Results of a Pilot Study. Psychotherapy, 49(1), 72‐80. Hill, R. M., & Pettit, J. W. (2014, July). Perceived Burdensomeness and Suicide‐Related Behaviors in Clinical Samples: Current Evidence and Future Directions, 70(7), 631‐643. Khan, M. M., & Mian, A. I. (2010, June). The one truly serious philosophical problem: Ethical aspects of suicide. International Review of Psychiatry, 22, 3rd ser., 288‐293.

References

Know the Warning Signs of Suicide. (n.d.). Retrieved September 22, 2016, from http://www.suicidology.org/resources/warning‐signs Rudd, M., Goulding, J. M., & Carlisle, C. J. (2013). Stigma and Suicide Warning Signs. Archives of Suicide Research, 17(3), 313‐318. SAFE‐T: Suicide Assessment Five‐step Evaluation and Triage for Mental Health Professionals. (2009). Retrieved September 30, 2016, from http://www.integration.samhsa.gov/images/res/SAFE_T.pdf Safety Planning Guide. (n.d.). Retrieved September 23, 2016, from http://www.sprc.org/sites/default/files/SafetyPlanningGuide Quick Guide for Clinicians.pdf Screening Tools. (n.d.). Retrieved September 21, 2016, from http://www.integration.samhsa.gov/clinical‐ practice/screening‐tools

• Suicide. (2015). Retrieved September 24, 2016, from http://www.cdc.gov/violenceprevention/pdf/suicide‐datasheet‐

a.pdf Suicide Myths. (n.d.). Retrieved September 26, 2016, from http://www.suicide.org/suicide‐myths.html Suicide Statistics. (n.d.). Retrieved September 24, 2016, from https://afsp.org/about‐suicide/suicide‐statistics/

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References

Suicide: Oregon 2016 Facts & Figures. (n.d.). Retrieved September 24, 2016, from https://afsp.org/about‐suicide/state‐ fact‐sheets/#Oregon Understanding Suicide. (2015). Retrieved September 24, 2016, from http://www.cdc.gov/violenceprevention/pdf/suicide_factsheet‐a.pdf Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Breathwaite, S., Selby, E. A., & Joiner, T. E., Jr. (2010, April). The Interpersonal Theory of Suicide. Psychological Review, 117(2), 575‐600. Washington County, Oregon Suicide Statistics [Pamphlet]. (2016). Hillsboro, OR: Washington County Public Health and Human Services.