Assessing Risk for Suicidein the Primary Care Setting

Presented by: Jonathan Betlinski, MDDate: 10/02/2014

Disclosures and Learning Objectives

• Learning Objectives– Know the five steps of Suicide

Assessment– Know at least three screening tools– Know ORS as it relates to involuntary

holds placed outside hospitals– Know at least two numbers to call

Disclosures: Dr. Jonathan Betlinski has nothing to disclose.

Assessing for Risk of Suicide

• Review risk factors for suicide

• Review SAFE-T and other screening tools

• Reminder of legal responsibility

• Next Week's Topic

Risk Factors for Suicide

Suicide is the 10th leading cause of death– 2nd in age 25-34, 3rd in age 15-24

Suicide rate is 17.6 per 100,000 people– The rate increased 30% from 1999 to 2010

Having a mood disorder increases risk 20x– Mood disorders account for 50%

– Schizophrenia accounts for 14%

– Personality Disorders account for 14%http://www.nytimes.com/2013/05/03/health/suicide-rate-rises-sharply-in-us.html?_r=0

http://books.google.ca/books?id=fV8_1u0c7l0C&pg=PA31#v=onepage&q&f=false

More Risk Factors for Suicide

• 8.6% lifetime risk for psychiatric inpatients• 20% of those who die have a prior attempt

– 1% of attempts will die within one year– 5% of attempts will die in 10 years

• 25-40% got any MH services last year• 20% saw an MHP in the last month• 45% saw their PCP in the last monthhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146379/pdf/mayoclinproc_86_8_011.pdf

http://www.bbmh.manchester.ac.uk/cmhr/research/centreforsuicideprevention/nci

Suicide and Firearms

• People who have access to a firearm are three times more likely to commit suicide

• Men with home access to a firearm are four times more likely than women to commit suicide with a firearm

• Men with home access to a firearm are ten times more likely to die by suicide with a firearm then men with no home access

• Attempting suicide with a firearm results in death 90% of the time

http://annals.org/article.aspx?articleid=1814426

http://www.mentalhelp.net/poc/view_index.php?idx=119&d=1&w=5&e=28649

SAFE-T (Suicide Assessment Five-step Evaluation and Triage)

• Identify Risk Factors– Note those that can be modified

• Identify Protective Factors– Note those that can be enhanced

• Conduct Suicide Inquiry• Determine Risk Level/Intervention• Document

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

Identify Risk Factors

Ideation – threatened or communicated

Substance abuse – excessive or increased

Purposeless – no reason 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

Mood Changes (dramatic)http://store.samhsa.gov/shin/content//SVP06-0153/SVP06-0153.pdf

Identify Protective Factors

• Internal– Sense of responsibility

– Life satisfaction

– Positive Coping and Problems-solving Skills

– Reality Testing Ability

• External– Children in the home and/or pregnancy

– Religiosity

– Positive Social Support

– Positive Therapeutic Relationshiphttp://www.integration.samhsa.gov/images/res/SAFE_T.pdf

http://psychiatryonline.org/content.aspx?bookID=28&sectionID=1673332#56073

Conduct Suicide Inquiry

• Ask the person directly if he or she– Is having suicidal thoughts/ideas– Has a plan to do so– Has access to lethal means

• “Are you thinking about killing yourself?”• “Have you thought of ways that you

might hurt yourself?”• Asking does not increase risk!http://store.samhsa.gov/shin/content//SVP06-0153/SVP06-0153.pdf

Determine Risk Level / Intervention

• NSW Risk Assessment Guide– http://www0.health.nsw.gov.au/pubs/2004/pdf/community_mental_hlt.pdf

• CSUS Suicide Risk Assessment– http://www.csus.edu/indiv/b/brocks/Workshops/District/2.Suicide%20Risk%20Assessment%20Su

mmary.pdf

• ACP Assessment of Suicidal Ideation– http://www.acponline.org/acp_press/essentials/cdim_ch30_wed05.pdf

• Harvard Risk Management Guidelines– https://www.rmf.harvard.edu/Guidelines-Algorithms/2011/~/media/Files/_Global/KC/PDFs/

suicideAs

• SAMHSA Grid– http://www.integration.samhsa.gov/images/res/SAFE_T.pdf

Determination of Risk / Intervention

• BHS – ED• MHTS• MSHR• ReACT Self

Harm Rule• Beck's SIS• DSI – SShttp://www.guideline.gov/content.aspx?id=47355

• GDS• RAM• SIQ• SIQ – JR• VASA• NGASR• RSQ

Now What?

• Do not leave the person unattended• Call County Crisis Line or 800.273.TALK

– Clackamas 503.655.8585– Multnomah 503.988.4888– Washington 503291.9111

• Arrange for transport to the nearest available hospital for evaluation

• “Safety contracts” don't prevent suicide http://store.samhsa.gov/shin/content//SVP06-0153/SVP06-0153.pdf

Legal – ORS 426.231

• (1) A physician licensed by the Oregon Medical Board may hold a person for transportation to a treatment facility for up to 12 hours in a health care facility licensed under ORS chapter 441 and approved by the Oregon Health Authority if:– (a) The physician believes the person is dangerous

to self or to any other person and is in need of emergency care or treatment for mental illness;

– (b) The physician is not related to the person by blood or marriage; and

– (c) An admitting physician at the receiving facility consents to the transporting.

http://www.oregonlaws.org/ors/426.231

Legal, Part II – ORS 426.231, Continued

• (2) Before transporting the person, the physician shall prepare a written statement that:– (a) The physician has examined the person within

the preceding 12 hours;

– (b) An admitting physician at the receiving facility has consented to the transporting of the person for examination and admission if appropriate; and

– (c) The physician believes the person is dangerous to self or to any other person and is in need of emergency care or treatment for mental illness.

• (3) The written statement required by subsection (2) of this section authorizes a peace officer, an individual authorized under ORS 426.233 (Authority of community mental health program director and of other individuals) or the designee of a community mental health program director to transport a person to the treatment facility indicated on the statement. [1993 c.484 §3; 1997 c.531 §3; 2009 c.595 §403; 2013 c.360 §39]

http://www.oregonlaws.org/ors/426.231

Summary

• Suicide rates are increasing• Most people with SI do not die by suicide• The best get it right only 70% of the time• Best strategy is to be gentle and direct,

AND use an established screening tool such as SAFE-T

• Call for help!• Be sure to document your rationale• Stick around for SKA2 blood test?

The End!

Next Week's

Topic:

Assessing Bipolar

Disorder in the Primary Care Setting