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UW PACCPsychiatry and Addictions Case ConferenceUW Medicine Psychiatry and Behavioral SciencesHow do I do a proper suicide assessmentand document it in my note?September 27, 2018Christopher R. DeCou, PhDUW PACC 2018 University of Washington

GENERAL DISCLOSURESThe University of Washington School ofMedicine also gratefully acknowledges receipt ofeducational grant support for this activity fromthe Washington State Legislature through theSafety-Net Hospital Assessment, working toexpand access to psychiatric services throughoutWashington State.UW PACC 2018 University of Washington

SPEAKER DISCLOSURES Any conflicts of interest?UW PACC 2018 University of Washington

LEARNING OBJECTIVES Orient to suicide epidemiology and facts Identify risk factors and drivers for suicidalbehavior Review standard-of-care for addressingsuicidality:I. Suicide-specific assessmentII. Detailed Safety PlanIII. Appropriate Referral & Follow-upUW PACC 2018 University of Washington

“An act with a fatal outcome which the deceased,knowing or expecting a potentially fatal outcome, hasinitiated and carried out with the purpose of bringingabout wanted changes.”(De Leo, et al. 2004)UW PACC 2018 University of Washington

KEY TERMS Died by Suicide (completed, suicided; never ‘successful’‘committed’) Attempted Suicide (Aborted, Rescued, Interrupted, Nonfatal) Survivor (Loss, Attempt) Suicidal Plans, Preparation, Rehearsal Suicidal Threats Instrumental Suicidal Behavior Non-Suicidal Self-Injury (NSSI) Suicidal Ideation (Passive, Active, Intent, MorbidRuminations)UW PACC 2018 University of Washington

Worldwide, one suicide death every 40 seconds.UW PACC 2018 University of Washington

UW PACC 2018 University of Washington

IN THE UNITED STATES Approximately 46,000 deaths per year 10th ranking cause of death overall, 2nd among youngpeople More than 1,000,000 attempts per year More than 6,000,000 people seriously consideredsuicide Approximately half of suicide deaths occur by firearmsUW PACC 2018 University of Washington

UW PACC 2018 University of Washington

UW PACC 2018 University of Washington

UW PACC 2018 University of Washington

CORE ASSUMPTIONS Suicide is a complex and fearsome behavior Risk for lethal self-harm (suicidal behavior) unfoldsover time People who die by suicide have both a desire fordeath and the acquired capability for enactingsuicidal behavior Individual suicides are not predictable, but risk canbe reduced with timely access to appropriate careUW PACC 2018 University of Washington

RISK FACTORSUW PACC 2018 University of Washington

Suicidal IdeationSuicide PlanSuicide PreparationSuicide RehearsalHistory of Suicidal BehaviorHealth ProblemsChronic/Impairing PainSleep ProblemsRecent/New DisabilityHistory of Psychiatric IllnessHistory of PsychiatricTreatmentLegal/Financial IssuesHousing ConcernsShameImpulsivitySubstance Use (Dependencev. Abuse)Significant LossRelationship ProblemsBurden to OthersPsychological PainStressAgitationHopelessnessSelf-Hate(Jobes, 2016; Linehan, 1993; Joiner 2009)UW PACC 2018 University of Washington

Jones et al., 2013UW PACC 2018 University of Washington

WARNING SIGNSIdeationSubstance awalAngerRecklessnessMood ChangesAmerican Association of SuicidologyUW PACC 2018 University of Washington

NOW WHAT?UW PACC 2018 University of Washington

RECOMMENDED STANDARD CAREELEMENTS Identify/Screen patients at intake & periodicallyfor suicidality Stratify according to level of risk (low, moderate,high) Develop collaborative Safety Plan Update every visit until risk is reduced/resolved Engage patient in Outpatient Treatment(National Action Alliance for Suicide Prevention, 2018)UW PACC 2018 University of Washington

GOALS OFASSESSMENT/MANAGEMENT1. Characterize & understand current suicidality2. Identify risk factors & Psychiatric History3. Develop detailed safety plan4. Establish follow-up/referral care5. Document standard of careUW PACC 2018 University of Washington

CURRENT SUICIDALITY: DESIRE FORSUICIDE “Are you having any thoughts of hurting orkilling yourself?” “Do you ever have thoughts of wanting to bedead or thoughts that you would be better offdead?” Thoughts/images of killing themselves or oftheir dead bodyJoiner et al., 2009UW PACC 2018 University of Washington

CURRENT SUICIDALITY: THWARTEDBELONGINGNESS “Do you feel connected to other people?” “Do you live alone?” “Who can you turn to when you feel bad orneed help?”Joiner et al., 2009UW PACC 2018 University of Washington

CURRENT SUICIDALITY: PERCEIVEDBURDENSOMENESS “Sometimes people think, ‘the people in my life wouldbe better off if I was gone.’ Do you think that?” “How would your family respond to your death bysuicide?” “What contribution do you make to the lives of thosearound you?”Joiner et al., 2009UW PACC 2018 University of Washington

ACQUIRED CAPABILITY Detailed History of Attempts, Plans, Threats, NSSI(date, method/means, medical care, rescued/aborted) Access to Lethal Means Painful & Provocative Events Patterns over time Chain Analysis for recent behaviorsJoiner et al., 2009UW PACC 2018 University of Washington

SUICIDE ASSESSMENT DECISION TREE(RISK y)?YesAny othersignificant finding AT LEASTModerate RiskNoElevated onResolved Plans &Preparation?YesAny othersignificant finding AT LEASTModerate Risk(Adapted from Joiner et al., 1999; 2009)NoElevated onSuicidal Desire &IdeationYesAny othersignificant finding AT LEASTModerate RiskNoLow RiskUW PACC 2018 University of Washington

STRUCTURE OF BRIEF ASSESSMENT “Tell me the story of ” Past Attempts/Fearlessness About Death Resolved Plans & Rehearsal/Preparation Current Suicidality (Ideation, Intent) Ability/Willingness/Capacity to stay safe Brief review of crisis intervention options Chart Review/Collateral Information(Adapted from Joiner et al., 1999; 2009)UW PACC 2018 University of Washington

(Joiner et al., 1999; 2009)UW PACC 2018 University of Washington

HELPFUL ASSESSMENT/MANAGEMENTTOOLS Columbia Suicide Severity Rating Scale (C-SSRS) Suicide Behavior Questionnaire – Revised (SBQR) Linehan Risk Assessment and ManagementProtocol (LRAMP) Collaborative Assessment & Management ofSuicidality (CAMS) Dialectical Behavior Therapy (DBT)UW PACC 2018 University of Washington

http://cssrs.columbia.edu/UW PACC 2018 University of Washington

http://cssrs.columbia.edu/UW PACC 2018 University of Washington

SAFETY PLANNING & CRISISINTERVENTIONUW PACC 2018 University of Washington

SAFETY PLAN Triggers/Antecedents/Vulnerabilities Internal/Individual Coping Strategies Social Support (non-suicide-specific) Specific contact info to prevent suicide Crisis Intervention/On-Call Resources(Not a ‘No Suicide Contract’)UW PACC 2018 University of Washington

CRISIS INTERVENTION Family Friends Provider/Therapist/Case Manager Crisis Lifeline Emergency DepartmentUW PACC 2018 University of Washington

MEANS RESTRICTION Assessment of highly lethal threats. Make it more difficult for patient to accessdangerous objects. Creativity and collaboration. Managing the ubiquity of dangerous objects.UW PACC 2018 University of Washington

REFERRAL & FOLLOW-UPVoluntary psychiatric inpatient careIncrease weekly visits with therapistPhone consultation/supportUW PACC 2018 University of Washington

CONTINGENT SUICIDALITY/SUICIDALBEHAVIOR Limited empirical evidence. Contingently suicidal less likely to engage insuicidal behavior (Lambert et al., 1996; 2002) Reasons for refusing discharge typically centeron access to resources (e.g., homelessness)UW PACC 2018 University of Washington

HOW TO ADDRESS CONTINGENTSUICIDALITY.1.2.3.4.Define & DocumentSuicide Risk AssessmentDocument Interventions to Reduce RiskRationale for Discharge; Reason Care isContraindicated5. Document Discussion of Discharge & ProblemSolving6. Consult & Document ConsultationBundy et al., 2014UW PACC 2018 University of Washington

DOCUMENTATION Precision in describing suicidal thoughts and behavior. Distinguish between attempts, NSSI, and instrumentalbehavior. Use quotes to articulate patient’s perceptions of safetyplanning. Note consultation w/ other providers, collateral contacts. Note VIP conversation.UW PACC 2018 University of Washington

OTHER HELPFUL TOOLSUW PACC 2018 University of Washington

CHRIS DECOUDECOU@UW.EDUUW PACC 2018 University of Washington

Suicidal Desire & Ideation Yes No Any other significant finding AT LEAST Moderate Risk . Any other significant finding AT LEAST Moderate Risk Any other significant finding AT LEAST Moderate Risk Low Risk (Adapted from Joiner et al., 1999; 2009) SUICIDE ASSESSMENT DECISION TREE (RISK STRATIFICAITON)