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Overview Malpractice issues Suicide Risk Assessment and - - PDF document

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Overview Malpractice issues Suicide Risk Assessment and Malpractice Prevention Suicide risk factors Suicide assessment Suicide in diagnoses Phillip J. Resnick, MD Video exercise Professor of Psychiatry Case Western

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SLIDE 1

Suicide Risk Assessment and Malpractice Prevention

Phillip J. Resnick, MD

Professor of Psychiatry Case Western Reserve University Cleveland, Ohio

Overview

  • Malpractice issues
  • Suicide risk factors
  • Suicide assessment
  • Suicide in diagnoses
  • Video exercise

Malpractice Issues Malpractice Standard

Simon RI. Therapeutic Risk Management of the Suicidal Patient. In: Simon RI, et al (Eds). Textbook of Suicide Assessment and Management. Second Edition. Arlington, VA: American Psychiatric Publishing; 2012.

A clinician is required to exercise that reasonable degree of knowledge and skill which is ordinarily possessed by

  • ther members of his profession in

similar circumstances.

Clinician Errors

Tsao CI, et al. Compr Psychiatry. 2007;48(4):309-312.

  • Errors of Fact – failure to obtain

relevant data

  • Errors of Judgment – act in good

faith after exercising requisite care

Risk Factors for Suicide

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SLIDE 2

Risk Factor Classification

Dynamic — subject to change by intervention Static — not subject to change by intervention

Static Risk Factors

Work Group on Suicidal Behaviors. Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. November 2003. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. Accessed April 17, 2017.

  • Male > Female
  • White > Black
  • Teenagers and men > 60
  • Unmarried

Static Risk Factors

Work Group on Suicidal Behaviors. Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. November 2003. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. Accessed April 17, 2017.

  • Past suicide attempts
  • Family history of suicide
  • Chronic medical illness

Dynamic Risk Factors

Work Group on Suicidal Behaviors. Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. November 2003. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. Accessed April 17, 2017.

  • Current suicidal thoughts
  • Current psychiatric illness
  • Substance abuse
  • Unemployment

Dynamic Risk Factors

Work Group on Suicidal Behaviors. Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. November 2003. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. Accessed April 17, 2017.

  • Feelings of hopelessness
  • Lack of social support
  • Life crises

– Rejection – Fall in status

Acute Risk Factors

Fawcett J. Diagnosis, Treatment, and Management of Suicide. Primary Psychiatry. 2005;232-234.

  • Severe psychic anxiety
  • Anxious ruminations
  • Global insomnia
  • Recent alcohol use
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SLIDE 3

Acute Risk Factors

Fawcett J. Diagnosis, Treatment, and Management of Suicide. Primary Psychiatry. 2005;232-234.

  • Severe psychic anxiety
  • Anxious ruminations
  • Global insomnia
  • Recent alcohol use

Comorbidity and Suicide

Nock MK, et al. Mol Psychiatry. 2010;15(8):868-876.

  • Depression predicts suicidal ideas
  • Anxiety and poor impulse control

predict suicide attempts

Assessment of Suicidality Suicide Ladder

Simon RI. Therapeutic Risk Management of the Suicidal Patient. In: Simon RI, et al (Eds). Textbook of Suicide Assessment and Management. Second Edition. Arlington, VA: American Psychiatric Publishing; 2012.

Wish you were dead? Suicidal thoughts? Suicidal method? Suicidal intent? How close have you come?

Suicide Ladder

Simon RI. Therapeutic Risk Management of the Suicidal Patient. In: Simon RI, et al (Eds). Textbook of Suicide Assessment and Management. Second Edition. Arlington, VA: American Psychiatric Publishing; 2012.

Wish you were dead? Suicidal thoughts? Suicidal method? Suicidal intent? How close have you come?

Aborted Attempts

Jobes DA. Managing Suicidal Risk: A Collaborative Approach. Second Edition. New York, NY: Guilford Press; 2016.

  • Intent to die
  • Change of mind immediately before

attempt

  • Absence of injury
  • Associated with actual attempts
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SLIDE 4

Cumulative Probabilities

Kessler RC, et al. Arch Gen Psychiatry. 1999;56(7):617-624.

Suicidal 34% suicidal plan ideas 26% unplanned attempt Suicidal plan 72% suicide attempt

Near Lethal Attempts

Levin A. Understanding Access to Means of Suicide Opens Doors to Prevention. Psychiatric News. 2015;50(2):9, 29.

Suicidal ideas began:

  • 24% within 5 minutes
  • 70% within 1 hour

Protective Factors

US Public Health Service. The Surgeon General’s Call to Action to Prevent Suicide. Washington DC: 1999:8-10. https://profiles.nlm.nih.gov/ps/access/nnbbbh.pdf. Accessed April 17, 2017.

  • Responsibility to family
  • Fear of the actual act
  • Fear of the unknown
  • Fear of social disapproval
  • Religious belief it is wrong

Protective Factors

US Public Health Service. The Surgeon General’s Call to Action to Prevent Suicide. Washington DC: 1999:8-10. https://profiles.nlm.nih.gov/ps/access/nnbbbh.pdf. Accessed April 17, 2017.

  • Pregnancy
  • Positive coping skills
  • Positive social support
  • Positive therapeutic

relationship

Protective Factors

US Public Health Service. The Surgeon General’s Call to Action to Prevent Suicide. Washington DC: 1999:8-10. https://profiles.nlm.nih.gov/ps/access/nnbbbh.pdf. Accessed April 17, 2017.

  • Pregnancy
  • Positive coping skills
  • Positive social support
  • Positive therapeutic

relationship

Path to Suicide

Chu C, et al. J Clin Psychol. 2015;71(12):1186-1200.

  • Suicidal idea
  • Suicidal plan
  • Suicidal preparation
  • Suicidal rehearsal
  • Suicidal act
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SLIDE 5

Suicidal Plan

Jobes DA. Managing Suicidal Risk: A Collaborative Approach. Second Edition. New York, NY: Guilford Press; 2016.

  • Specificity of plan
  • Availability of lethal method
  • Actual preparation

Meaning of Death Suicide Attempt Assessment

Simon RI. Therapeutic Risk Management of the Suicidal Patient. In: Simon RI, et al (Eds). Textbook of Suicide Assessment and Management. Second Edition. Arlington, VA: American Psychiatric Publishing; 2012.

  • Isolation and timing
  • Acting to get help
  • Final acts, eg, will
  • Suicide notes

Patient’s Report

Simon RI. Therapeutic Risk Management of the Suicidal Patient. In: Simon RI, et al (Eds). Textbook of Suicide Assessment and Management. Second Edition. Arlington, VA: American Psychiatric Publishing; 2012.

  • Intent and expectations
  • Relationship to substances and

stressors

  • Aborted attempts

Suicide Risk Assessment

Shea SC. Suicide Assessment Part 1: Uncovering Suicidal Intent—A Sophisticated Art. Psychiatric

  • Times. December 3, 2009.
  • Statements about suicidality
  • Past suicide attempts
  • Hopelessness
  • Psychotic symptoms

Suicide Assessment

Although Mr. Jones denies any suicidal ideas, his risk is moderate due to his history

  • f

2 past suicide attempts, severe depression with delusions, and acute anxiety.

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SLIDE 6

Although Mr. Smith reports suicidal ideas, they are no worse than they have been intermittently for the last 3

  • years. Furthermore, suicide risk is low

because

  • f

no prior attempts, no access to firearms, a future orientation, and a strong therapeutic relationship.

Suicide Risk

  • Minimal
  • Moderate
  • Severe

No-Suicide Contracts

Simon RI. Therapeutic Risk Management of the Suicidal Patient. In: Simon RI, et al (Eds). Textbook of Suicide Assessment and Management. Second Edition. Arlington, VA: American Psychiatric Publishing; 2012.

  • False sense of security
  • Significant if refused
  • Need for working alliance
  • Significance of prior violations

Losses in Suicide

  • Life
  • Family
  • Future
  • Risk of eternal damnation
  • Stigmatization of children

Emotions Evoked in Family by Suicide

  • Anger
  • Sadness
  • Betrayal
  • Guilt

Inpatient Suicide

Jabbarpour YM, et al. Focus. 2011;9(2):186-193. Busch KA, et al. J Clin Psychiatry. 2003;64(1):14-19.

  • 6% of US suicides
  • 78% denied suicidal ideas
  • 51% were on q 15 min checks
  • High risk shortly after discharge
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SLIDE 7

Attitude Toward Therapist

Resnick PJ. Recognizing that the Suicidal Patient Views You as an Adversary. Current Psychiatry. 2002;1(1):8.

  • Ally — desire to live
  • Adversary — after decision to die

Adversaries

Resnick PJ. Recognizing that the Suicidal Patient Views You as an Adversary. Current Psychiatry. 2002;1(1):8.

  • The patient’s goal is to die by suicide
  • The therapist’s goal is to prevent the

suicide

Patient Question

Why would I tell you I had a suicidal plan if I really wanted to kill myself?

Implications

  • Do not accept disavowal of

suicidal plans at face value

  • Look for objective signs of

improvement

  • Involve family in treatment

Tell Relatives to Report

  • Talk of suicide
  • Talk of giving up
  • Putting affairs in order
  • Final goodbyes
  • Acquiring a weapon

Final Suicidal Goodbyes

Robins E, et al. Am J Psychiatry. 1959;115(8):724-733.

  • 60% to spouses
  • 50% to relatives
  • 18% to therapists
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SLIDE 8

Suicidal Behavior

Centers for Disease Control and Prevention. Suicide: Facts at a Glance, 2012. https://stacks.cdc.gov/view/cdc/21865. Accessed April 17, 2017.

  • 25 attempts for each completed

suicide

  • 90% of attempters do not die by

suicide

  • Major risk factor

Suicide Risk

Jacobs DG. The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco, CA: Jossey-Bass; 1999.

PREVIOUS ATTEMPT MOOD DISORDERS Depression Bipolar SUBSTANCE ABUSE Opiates Alcohol SCHIZOPHRENIA

10 20 30 40

Number of Times the Expected Rate

Methods of Successful Suicide

Work Group on Suicidal Behaviors. Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. November 2003. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. Accessed April 17, 2017.

Firearms 55%–60% Hanging 14% Poisons 11% Gas 9% Other 8%

Guns and Suicide

Kellermann AL, et al. N Engl J Med. 1992;327(7):467-472. Levin A. Understanding Access to Means of Suicide Opens Doors to Prevention. Psychiatric News. 2015;50(2):9, 29. The National Academies of Science Engineering Medicine. Means of Violence — A Workshop. December 18-29, 2014. www.nationalacademies.org/hmd/Activities/Global/ViolenceForum/2014-DEC-18.aspx. Accessed April 17, 2017.

  • Persons who live in a home with a

firearm are 5 × more likely to die by suicide

  • For children the increase is 10-fold

Methods of Successful Suicide

Work Group on Suicidal Behaviors. Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. November 2003. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. Accessed April 17, 2017.

Firearms 55%–60% Hanging 14% Poisons 11% Gas 9% Other 8%

Suicide Exercise

  • Suicide risk factors
  • Deterrents to suicide
  • Admit to hospital?
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SLIDE 9

Suicide Exercise

  • Suicide risk factors
  • Deterrents to suicide
  • Admit to hospital?

Treatment Plan

CBT = cognitive-behavioral therapy.

  • Depression
  • Addiction
  • Poor support
  • Hopelessness
  • Medications,

therapy

  • Program
  • Family intervention
  • CBT

Decreased Outpatient Suicide Risk

Bongar B, et al. Suicide Life Threat Behav. 1992;22(4):453-478.

  • Remove weapons — firearms
  • Increase office visits
  • Contact family or friends
  • Periodic telephone check in

Suicide Risk Assessment

Simon RI. Preventing Patient Suicide: Clinical Assessment and Management. First Edition. Arlington, VA: American Psychiatric Publishing; 2010.

  • Risk factors
  • Protective factors
  • Risks and benefits of hospital

admission

Benefits of Hospitalization

Bongar B, et al. Suicide Life Threat Behav. 1992;22(4):453-478.

  • Reduced risk of suicide
  • Away from stressful situation

Risks of Hospitalization

Bongar B, et al. Suicide Life Threat Behav. 1992;22(4):453-478.

  • Decreased self-esteem
  • Stigmatization
  • Financial burden
  • Disruption of the therapeutic

relationship

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SLIDE 10

Documentation

Lambert K. Risk Management Considerations When Treating Suicidal Patients. Psychiatric News. 2017;52(1):17.

  • Efforts to contact family
  • Firearms inquiry
  • Rationale for decision

regarding level of care “Documentation is like sex: When it is good, it is very, very good; and when it is bad, it is better than nothing.”

—Dick Brandon

A standard

  • f

care exists for the assessment of suicide risk, but not for the prediction of suicide.

Take-Aways

  • 1. Once a patient has decided to

commit suicide, he perceives the clinician as an adversary rather than an ally

  • 2. Although depression predicts suicidal

ideas, anxiety and poor impulse control predict suicide attempts

  • 3. Documentation of suicide risk

assessment is the best way to avoid malpractice suits

Chinese Proverb

  • Tell me: I forget
  • Show me: I remember
  • Involve me: I understand