powerpoint presentation - suicide_basic - cbhc

University of Colorado

Depression Center

© M. Allen 2010

1

Driving Toward Zero: Preventing Suicide in Your Organization

September 28,2013

Michael H. Allen, M. D.

Professor of Psychiatry and Emergency Medicine

University of Colorado School of Medicine

Director of Research

University of Colorado Depression Center

Senior Investigator

VISN 19 Mental Illness Research, Education and Clinical Center


Depression Center

Outline

1. 2012 Stats

2. Individual Level

A. Review of Risk Factors, Warning Signs

B. Suicidal Process

C. “Must Know” Elements of Assessment

D. SAFE – T

E. Joiner’s Model: Desire, Intent, Capability

I. Risk Stratification

II. Cases

F. Intervention

© M. Allen 2010

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Depression Center

Outline

3. System

A. Strategy

B. Failures

C. Quality

D. Programmatic Improvements

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Depression Center

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Suicide Rates, US and Colorado R

ate

/10

0,0

00

0

5

10

15

20

25

199019

9119

9219

9319

9419

9519

9619

9719

9819

9920

0020

0120

0220

0320

0420

0520

0620

0720

0820

0920

1020

1120

12

Crude rates

Healthy People 2000 Goal 6.1 Reduced 10% to 10.5

Colorado

United

States

1053

http://webappa.cdc.gov/sasweb/ncipc/mortrate10_sy.html


Depression Center

© M. Allen 2010

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Suicidal thinking is common

Lifetime ECA, 80’s

Lifetime NCS, 80’s

1 Year ICARIS, ‘94

Ideation 11.2% 13.5% 5.6%

Plan 3.9 2.7

Attempt 3.1 4.6 .7

ECA, lifetime, 1980’s

NCS lifetime, n= 5877, 1990’s

Crosby AE, et al. SLTB 1999; 29:131. n=5238

>10% think about it in their lifetime


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Adolescence

Common over 18 months 6-7 grade

60.5% endorsed at least one item

32.9% thoughts of death and dying

6% thought of killing themselves

Generally declined over this period

2% had persistently high SI

Vander Stoep A, et al. SLTB 2009;39(6):599


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About 4% experience suicidal thoughts each year.

About 1/4 of those with SI make suicidal plans.

About 1/3 of those make an attempt.

About 1 in 15 or 20 die.


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Most do not volunteer the information

Different settings

Community survey

– 44% with SI saw no need for treatment

• 38% received care vs 73%

Mental health centers

– 73% did not report SI

Inpatient or recent discharges

– 78% denied SI and 28% had “contract”


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Most who die, die on first attempt,

78% by the second attempt.

0% 50%

Isometsa,1998

Conwell,1998

Roy, 1982

Subsequent First

Roy A. Arch Gen Psych 1982, 39:1089.

Conwell Y, et al: Am J Geri Psych 1998, 6:122-126.

Isometsa ET : Br J Psychiatry 1998 173: 531-535

56 22 9 13

68 21 6 5

0% 25% 50% 75% 100%

All

Male

>45

2/3 of males over 45


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Most likely to do it,

Least likely to talk about it

Attempters, n = 211

Prior verbalization not correlated with wish

o to die at time of subsequent attempt

Talking related to personality style,

not level of despair

Suffer in silence or

emit coded warning signals

Kovacs, et al. Arch Gen Psych 33:198, 1976


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Particularly True of Adolescents

Risk of Medically Treated Attempts in Adolescents

1999 Youth Risk Behavior Survey

High risk sex

Binge drinking

Drug use

Violence

Eating

Smoking

0

10

20

30

40

50

Od

ds

of

Att

em

pt

1 2 3 4 5# Behaviors

17% of youths 4-6 behaviors - 60% of attempts

1.2% all 6 – 16% of attempts

Miller TR and Taylor DM. SLTB 35(4):425-435, 2005

Colorado Suicide Deaths Age and Gender, 2007-2011

Source: COVDRS

31

427

503

606

749

509

203 172

74

13

110 146

195

266

161

53 28 11

0

100

200

300

400

500

600

700

800

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Nu

mb

er

of

Suic

ide

s

Age Group (years)

Males Females


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Of men who survive an attempt,

almost 1/3 kill themselves over 25 years P

roport

ion S

urv

ivin

g

90%

70%

100%

80%

60%

Men

Women

10 20 30

Suominen, K. Am J Psychiatry 161(3): 562-563, 2004

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© M. Allen 2008

Violence and Suicide Capability

Conner et al. Am J Psych 2001; 158: 1701

4.61.5

6.9

11.6

1.5

6.9 8

Violent Alcohol

Alone

Violence

Alcohol

Violence

Alone

Male Violent

Male

Violent

Female

Violence sometimes or often increases risk

Particularly for women

Violence + alcohol not additive

Odds ratio, 95% CI


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Suicidal Process

Suicide

Facilitation

Survival

Inhibition

Acute Mood Change

Stress

Vulnerabilty

Joiner T.

Crisis

Safety Plan

Means

Substances

Supervision

Hope, pleasure

Acquired

Genetic Assessment

Risk factors

Warning signs


Depression Center My Own Top 8 Risk Factors

and Warning Signs

1. Prior attempt with intent to die

2. Worst SI ever

3. Substance abuse (increase)

4. Irritability, (reactive) aggression

5. Severe anxiety, agitation

6. Insomnia

7. Severe mental illness, hospitalization

8. Recent change in reasons for living

o Child/pet care, partner separation


Depression Center

Other Risk Factors or

Warning Signs?

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Depression Center Suicide Assessment Five Step

Evaluation and Triage (SAFE-T)

Suicide inquiry

Risk factors

Protective factors

Risk stratification and intervention

Documentation

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SAMHSA

Google “safe t suicide”

http://store.samhsa.gov/shin/content//SMA09-4432/SMA09-4432.pdf


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Depression Center

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Suicidal Desire

Suicidal ideation

Psychological pain

Perceived burden on others

Hopelessness; helplessnes

Mental illness

• Demoralization


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Suicidal Intent

Plan to kill self/other

Preparatory behaviors

Expressed intent to die

Attempt


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Suicidal Capability

History of suicide attempts

Exposure to someone else’s suicide

Exposure to violence

Available means of killing self/other

Intoxication

Chronic intoxication

Acute symptoms of mental illness

• Sleep disturbance, psychotic guilt

Extreme agitation/rage


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Protective Factors or Buffers

Immediate supports

Social supports

Planning for the future

Engagement with others, helpers

Ambivalence about living/dying

Core values/beliefs

Sense of purpose


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High Risk

Role of protective factors unclear

D=Desire C=Capability I=Intent

D C I


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Moderate to High Risk


Protective factors may influence risk

Desire paired with intent or capability

D I

D C


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Moderate to Low Risk


Any core factor presenting alone

Source: Joiner, Thomas. Establishing Standards for the Assessment of Suicide

Risk Among Callers to the National Suicide Prevention Lifeline. Suicide and

Life-Threatening Behavior. 2007;37(3):253-365.

D C I


Depression Center

SAFE-T Stratification

Highest level is most important

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Depression Center

Case

50 year old male career fire fighter

Anniversary of wife’s death

Gambling problem, impending bankruptcy

Appears distraught at work, sent to ER

Complains of severe insomnia

• Meds have not helped

Appears restless, anxious and guarded

Meets criteria for Major Depression

Some thoughts of death but denies SI

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Depression Center

SAFE-T Stratification

Highest level is most important

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What is Safety Planning?

• A brief clinical intervention

• Follows risk assessment

• A hierarchical and prioritized list of coping strategies and sources of support

• To be used during or preceding a suicidal crisis

• Involves collaboration between the patient and clinician

Stanley, B., & Brown, G.K. (with Karlin, B., Kemp, J.E., & VonBergen. H.A.). (2008). Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version. Retrieved from http://www.sprc.org/library/SafetyPlanTreatmentManualReduceSuicide RiskVeteranVersion.pdf

• Ways to increase collaboration

– Sit side-by-side

– Use a paper form

– Allow the client to write

• Brief instructions using the client’s own words

• Easy to read

• Address barriers and use a problem-solving approach

Tips for Developing a Safety Plan

Stanley, B., & Brown, G.K. (with Karlin, B., Kemp, J.E., & VonBergen. H.A.). (2008). Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version. Retrieved from http://www.sprc.org/library/SafetyPlanTreatmentManualReduceSuicide RiskVeteranVersion.pdf

• No-suicide contracts ask patients to promise to stay alive without telling them how to stay alive.

• No-suicide contracts may provide a false sense of assurance to the clinician.

• DON’T USE THEM! No Suicide Contract

“No-Suicide Contracts”

6 Steps of Safety Planning

• Step 1: Recognizing Warning Signs

• Step 2: Using Internal Coping Strategies

• Step 3: Utilizing Social Contacts that Can Serve as a Distraction from Suicidal Thoughts and Who May Offer Support

• Step 4: Contacting Family Members or Friends Who May Offer Help to Resolve the Crisis

• Step 5: Contacting Professionals and Agencies

• Step 6: Reducing the Potential for Use of Lethal Means

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Step 1: Recognize Warning Signs

• Purpose: To help the client identify and pay attention to his or her warning signs

• Recognize the signs that immediately precede a suicidal crisis

• Personal situations, thoughts, images, thinking styles, mood or behavior

• “How will you know when the safety plan should be used?”

• Specific and personalized examples

Step 2: Using Internal Coping Strategies

• Purpose: To take the client’s mind off of problems to prevent escalation of suicidal thoughts

– NOT to solve the client’s problems

• List activities the client can do without contacting another person

• This step helps clients see that they can cope with their suicidal thoughts on their own, even if only for a brief period of time

• Examples: Go for a walk, listen to inspirational music, take a hot shower, play with a pet

Step 2: Using Internal Coping Strategies

• Ask “How likely do you think you would be able to do this step during a time of crisis?”

• Ask “What might stand in the way of you thinking of these activities or doing them if you think of them?”

• Use a collaborative, problem solving approach to address potential roadblocks.

What would safety planning with this patient look like?

64 year old Vietnam Veteran was hospitalized in the context of alcohol use, worsening PTSD

symptoms and suicidal ideation with a plan to shoot himself. He has consistently been denying suicidal ideation since he was admitted to the

hospital following detox 5 days ago. He is requesting discharge from the hospital, stating

that he only experienced suicidal ideation because he was intoxicated.

Google

“VA safety plan quick guide”


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Strategy

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© M. Allen 2009

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Occult SI in 3-11.6% of ED Visits

Study Definition of Ideation Freq (%)

Allen (2013)

CSSRS Passive SI

CSSRS Active SI

Any SI and history or attempt

79/1068 (7.5)

24/1068 (2.25)

12/1068 (3.3)

ED-SAFE Retro Any mention of suicidal behavior 23 / 800 (2.9)

ED-SAFE TAU Any mention of suicidal behavior 2771 / 94,385 (2.9)

NIMH Multicenter

Allen MH, et al. Suicide Life Threat Behav 2013; 42 (3):313-323.

Suicide deaths by circumstance, 2007-2011

Source: COVDRS

N Percent*

Current depressed mood 2,507 62.6

Current mental health problem 1,682 42.0

Left a suicide note 1,603 40.0

Ever treated for mental health problem 1,584 39.5

Disclosed intent to die by suicide 1,539 38.4

Intimate partner problem 1,490 37.2

Crisis within two weeks of the suicide 1,393 34.8

Current mental health treatment 1,323 33.0 Physical health problem 1,277 31.9

Diagnosis of depression 1,251 31.2

History of previous suicide attempts 1,122 28.0

Problem with alcohol 1,075 26.8

Financial problem 903 22.5

Job problem 862 21.5

Problem with other substance 611 15.3 *Percent of total cases with at least one circumstance known; Colorado residents who died in Colorado


Depression Center

Driving Toward Zero

Aspirational goal

National Strategy

Possible bounded systems

Focus on suicide distinct from

treatment of mood disorders

oNOTE no mention of depression

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Depression Center US Institute of Medicine

“Crossing the Quality Chasm”

Conclusions

“In its current form, habits, and

environment, American health care is

incapable of providing … the quality of

health care it expects and deserves.”

“Current care…honors and protects

unscientific variations in care based on

local habits, unquestioned forms of

autonomy and insufficient curiosity.”

Berwick DM. Health Affairs 21(3):80, 2002




Six dimensions of care

Safety

Effectiveness

Patient-centeredness

Timeliness

Efficiency

Equity





Ten simple rules

6. “Do no harm” individual

responsibility

7. Secrecy necessary

Litigation

8. System reactive

9. Reduce costs

10. Traditional prof

roles over system needs

Safety a property

of systems

Quality requires

transparency

Anticipates needs

Reduce waste

Cooperation is a

priority





Ten rules for microsystems

1. Care based on visits

2. Professional autonomy drives

variability

3. Professionals control care

4. Information owned by

providers

5. Decision making based

on training, experience

Care is continuous

Customized to patient

needs, values

Patient controls care

Knowledge shared

Based on evidence,

not vary illogically



Depression Center

Henry Ford Health System

© M. Allen 2010

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Active mood disorder

Euthymic mood disorder

Gen’l pop

Henry Ford

Zero


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Preventability of Suicide

Victoria State, Australia

629 psychiatric patient suicides/5 yrs

67% prior attempt

49% attention within the prior 4 weeks

20% preventable

Burgess P, et al: Psych Services 51:1555, 2000


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Preventability of Suicide

National survey, England/Wales, 1 yr

2,370 of 10,040 suicides had MH contact

26 % drug noncompliance

28 % lost to follow up

Last contact, risk “absent” 30 %,

“low” 54 %, “mod” 13 % and “high” 2 %

22% preventable

Appleby L, et al. BMJ 318:1235, 1999


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Preventing the 20 %

Burgess et al, Appleby et al

Relationship

Assessment

– Risk assessment

– Comorbidity, Sx’s unrelated to 1° Dx

Treatment

– 10 % OD of psychotropics

– Nonadherence meds and appts


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Specialty Mental Health

Recommendations

Training

Regular assessment

Structured

Frequent, every visit in some cases

• Criteria for low / moderate / high

Safety planning

Means, environment

Support, supervision

Substance use

Hope, pleasure


Depression Center

Work Force Preparation

Qualifications are low and training is poor

Psychiatry: 91% - mean 3.6 hrs, 27% skills

Psychology: 50%

Social Work: less that 25%

Marriage and Family Therapists: 6%

Counselors: 2%

No state Continuing Education requirements

Schmitz W, et al. AAS Task Force Rep. SLTB 2012;42(3):292-304


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Tools

1. Question Persuade Refer (QPR)

o Different versions

2. Mental Health First Aid (MHFA)

3. Applied Suicide Intervention Skills Trng

(ASIST)

How many have attended one of these?


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Recommendations

Training

Improved assessment

Structured

Columbia Suicide Severity Rating Scale

Frequent, every visit in some cases

• Criteria for low / moderate / high

• Flagging or communicating risk

Safety planning

Means restriction

Small prescriptions, blister packs


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Training

Improved assessment

Safety planning

Treatment

• Measurement, eg, depression

• Goal “well”, not better

• Comorbid conditions, eg, anxiety

• Substance Abuse

• Patient centered

Man Therapy PSA

www.mantherapy.org

http://www.youtube.com/watch?v=EhH7SjbxsgU&noredirect=1

http://www.mantherapy.org/


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Training

Improved assessment

Safety planning

Treatment

Continuity and outreach

• Relationship issues

• Transitions between settings

• Suicide Prevention Coordinators

• HOME

• Missed appointment policy

• Call or visit

• Mobile Crisis

HOME Program Description

Risk assessment over the phone within 1 business day

Home visit within first week of discharge

-Risk assessment

-Review and revise discharge plan and safety plan

-Meet with support system

-Review upcoming appointments

Follow-up until engaged in care

How the Lifeline Works

• Callers dial 800-273-TALK or 800-SUICIDE

• Callers are connected to closest center

• “Press 1” for Veterans, Military

• Extensive back-up system ensures all calls

are answered

• Crisis workers listen, assess, and link/refer

callers to services, as needed

– Some centers professional, some volunteer

• Chat, text systems

VISN 19 MIRECC Website

http://www.mirecc.va.gov/

visn19/

Research

Education

Clinical Care

Assessment Tools

Fellowship Info

Personnel

Presentations

Study Participation

Contact Us

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