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Assessment of Suicide Risk Dr David Harniess MBChB MRCGP DCH DRCOG

Learning Objectives Rationale for importance of suicide risk assessment Identifying people at high risk of suicide Considering assessment tools Considering questioning techniques and practice in roleplay

Discussion in pairs Why do you think assessing for suicide risk is important? Do you think GPs can make a difference in reducing suicide in society? What has been your experience so far in assessing suicide risk?

Incidence and prevalence of suicide worldwide Globally 1.4% cause of global burden of disease In 2001 the yearly global toll from suicide exceeded the number of deaths by homicide (500 000) and war (230 000). Highest rates are found in Eastern Europe and the lowest are found mostly in Latin America, in Muslim countries and in a few of the Asian countries. There is little information on suicide from African countries. No data found on Libya [WHO Press release 2010 - website accessed 23/1/2011 http://www.who.int/mediacentre/news/releases/2004/pr61/en]

Current trends In the last 45 years suicide rates have increased by 60% worldwide. Suicide is among the three leading causes of death among those aged 15-44 years in some countries, and the second leading cause of death in the 10-24 years age group Rates among young people have been increasing to such an extent that they are now the group at highest risk in a third of countries, in both developed and developing countries. Suicide prevention (SUPRE) SUPRE Report [www.who.int website accessed on 23/1/11]

WHO Statistics Distribution of suicide rates globally (per 100 000) by gender and age, 2000 http://www.who.int/mental_health/prevention/suicide/suicide_rates_chart/en/index.html [website accessed 24/1/2011]

Map of Suicide Rates Globally http://www.who.int/mental_health/prevention/suicide/suicide_rates_chart/en/index.html [website accessed 24/1/2011]

Changes in Incidence of Suicide over recent decades in Australia Harrison, J. et al Youth Suicide and Self-Injury Australia Research Centre for Injury Studies Flinders Univeristy Adelaide

Small Group Discussion What do you think are the risk factors for increased risk of completing suicide? Are you aware of any screening tools to assess risk of suicide?

Risk factors for completing suicide Demographic Social Older age Social isolation Male Unemployment Clinical Co-morbidity Depressed mood state Previous suicidal attempt/self harm Substance misuse Serious intent Physical illness Hopelessness/wish to die Psychiatric disorder(i.e. anxiety Anxiety symptoms disorder, schizophrenia) History of depressive disorder Family history Other Access to means of suicide (weapons, drugs etc ) Palazidou, E. WONCA Working Party on Mental Health Workshop – Suicide risk

Beck’s Scoring system Objective Circumstances Related to Suicide Attempt Isolation 0 Somebody present 1 Somebody nearby, or in visual or vocal contact 2 No one nearby or in visual or vocal contact Timing 0 Intervention is probable 1 Intervention is not likely 2 Intervention is highly unlikely Precautions against discovery/intervention 0 No precautions 1 Passive precautions (as avoiding other but doing nothing to prevent their intervention; alone in room with unlocked door) 2 Active precautions (as locked door) Acting to get help during/after attempt 0 Notified potential helper regarding attempt 1 Contacted but did not specifically notify potential helper regarding attempt 2 Did not contact or notify potential helper

Beck’s Scoring System Final acts in anticipation of death (will, gifts, insurance) 0 None 1 Thought about or made some arrangements 2 Made definite plans or completed arrangements Active preparation for attempt 0 None 1 Minimal to moderate 2 Extensive Suicide Note 0 Absence of note 1 Note written, but torn up; note thought about 2 Presence of note Overt communication of intent before the attempt 0 None 1 Equivocal communication 2 Unequivocal communication

Self Report Alleged purpose of attempt 0 To manipulate environment, get attention, get revenge 1 Components of above and below 2 To escape, surcease, solve problems Expectations of fatality 0 Thought that death was unlikely 1 Thought that death was possible but not probable 2 Thought that death was probable or certain Conception of method's lethality 0 Did less to self than s/he thought would be lethal 1 Wasn't sure if what s/he did would be lethal 2 Equaled or exceeded what s/he thought would be lethal Seriousness of attempt 0 Did no seriously attempt to end life 1 Uncertain about seriousness to end life 2 Seriously attempted to end life Beck’s Scoring System

Attitude toward living/dying 0 Did not want to die 1 Components of above and below 2 Wanted to die Conception of medical rescuability 0 Thought that death would be unlikely if he received medical attention 1 Was uncertain whether death could be averted by medical attention 2 Was certain of death even if he received medical attention Degree of premeditation 0 None; impulsive 1 Suicide contemplated for three hours of less prior to attempt 2 Suicide contemplated for more than three hours prior to attempt 15-19 Low Intent 20-28 Medium Intent 29+ High Intent There is also a greater risk of repeated attempts the higher the intent rating. Beck’s Scoring system

BMJ Best Practice – Suicide Risk Assessment [www.bmj.com website accessed 24/1/11]

Some Comments on Assessment Tools Only a tool – may get in way of doctor-patient rapport and consultation Another factor not listed is chosen method of attempted death e.g. hangings & firearms vs poisoning Essential to collect information on the patient's psychiatric history (90% of people who commit suicide have a psychiatric diagnosis) Low validity at predicting who actually commits suicide – not substitute for clinician’s judgement High false positives

Group Discussion What questions would you use to assess serious intent of committing suicide? What areas in your assessment should you cover?

Suicide risk assessment has 4 steps: Assessment of the 5 components of suicide: ideation, intent, plan, access to lethal means, and history of past suicide attempts Evaluation of suicide risk factors Evaluation of current experience (what's going on?) Identification of targets for intervention. BMJ Best Practice – Suicide Risk Assessment [www.bmj.com website accessed 24/1/11]

Asking about suicidal ideation – some example questions Have you thought that your life is not worth living? Have you thought about ending your life? Do you feel that your reasons for living outweigh your reasons for dying? If you had a way, would you try to take your own life? If you thought you were going to die, would you take steps to save yourself? How often do you think about dying? How long does it usually take for the thoughts to go away? Are thoughts about dying or taking your life overpowering to you?

Asking about suicidal intent and plans – some example questions How do you feel when you start thinking about taking your own life? Have you ever thought of ways to take your own life? Have you ever had specific thoughts or plans about taking your own life? Have you set a time or place? What are those plans? Do you have access to (method) (e.g., pills, poisons, medication, weapon)? Do you think you could get (method) if you needed to? Do you think you would die if you used (method)? Have you done anything or taken steps to prepare to take your own life (e.g., writing suicide note or will, arranging method, giving away possessions)? Do you think that you could take your own life? Do you feel ready to die?

Roleplay – a chance to practice

Some Tips - Do’s and Don’ts DO’s Establish rapport. Use a calm, patient, non-judgmental, and empathic approach. Begin with supportive statements and open-ended inquiries. Start with open move towards more specific questions in a sensitive and non-judgmental way that creates an opportunity for dialogue; Do ask specific questions about self-harm, suicidal thoughts, plans, attitudes towards suicide, history of suicidal behaviour, thoughts of death, and feelings of hopelessness. DON’TS Allow your personal feelings and reactions to influence assessment and treatment. Rush the patient or ask leading questions. Interrogate the patient or force the patient to defend his or her actions. Minimise the patient's distress. Undermine the seriousness of the suicidal thought or action.

Approx 75% of completed suicides the individual had seen a doctor within the prior year before their death (45%-66% within the prior month) Empathy and listening Non- judgemental approach Identifying and treating any underlying psychiatric condition Support and ensuring patient safety Consider patient leaflets in waiting areas You can make a difference

Resources available WHO mhGAP Intervention Guide (www.who.int) SUPRE publications on WHO website `Preventing suicide: a resource for GPs’ BMJ Best Practice - Assessing Suicide Risk (www.bmj.com)

THANKS FOR LISTENING ANY QUESTIONS?

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