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Suicide and Risk Assessment

MS3 Lecture
by

Natalie Lester

on 20 October 2013

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Transcript of Suicide and Risk Assessment

a. Increased
b. Decreased
c. Remained constant
a. 15-24 years
b. 25-34 years
c. 35-64 years
d. 65+ years

In what age group is the suicide completion rate (incidence) highest?
Scope of the problem
38,000 Suicides/year

Homicides/year
Diabetes-related deaths
Breast cancer deaths
MVA deaths
a. Overdose/Ingestion
b. Cutting
c. Hanging/Suffocation
d. Firearms
e. Other
Which method of suicide prevention has been demonstrated as most effective?

a. Population screening
b. Gatekeeper education
c. Means restriction
d. Antidepressant treatment
e. Social cohesiveness
The Jumpers
On the bridge, Baldwin counted to ten and stayed frozen. He counted to ten again, then vaulted over. As he crossed the chord in flight,
Baldwin recalls,

“I instantly realized that everything in my life that I’d thought was unfixable was totally fixable—except for having just jumped.”

-Tad Friend, New Yorker, 2003

Follow-up of Golden Gate Bridge attempters
(Seiden, 1978)

515 individuals restrained from jumping
Median follow-up 27 years
25/515 died by suicide (5%)
6 from GGB, 1 from Bay Bridge
Two-thirds of suicides were within 6 months

Follow-up of London Underground attempts
(O’Donnell et al, 1994)
94 individuals survived attempts
10-13 year follow-up
9 suicides or probable suicides (10%)
All occurred within 3.5 years

What do we know from the Golden Gate jumpers?
16,000
69,000
41,000
42,000

Most common
method of suicide in U.S.?
Risk Assessment
Risk Factors
Protective Factors
"What keeps you from acting on these thoughts?"
Potentiating Factors
What makes a patient likely to act?

Impulsivity
Access to means
Active substance abuse
Insomnia
Physical pain
Akathisia
Hallucinations


Be Specific
History of previous attempts
Recent discharge
Family history of suicide
Demographic factors
Mental illness
Physical illness
Substance abuse
Access to means
Suicide attempt
Aborted attempt
Suicide intent with specific plan
Communication of intent
Consideration of means
Chronic SI thoughts
Fleeting SI thoughts
Passive death wish

Suicide and Risk Assessment
Natalie Lester, MD, MPH
MS3 lecture
October 24, 2013
How big a problem is suicide?
How can we prevent suicide?
(A public health perspective)
If we stop someone from committing suicide, will they just try again?
How can we assess risk?
How do we treat suicidal patients?
2) How can we prevent suicide?

(A public health perspective)
Means Matter
"Means Matter"
`
`
State variance in suicide rate is attributable to variance in firearm suicides
If we stop someone from committing suicide, will they just try again?
~10% of people with a near-lethal attempt will go on to die by suicide
Ages 15-24:
Third leading cause of death

Ages 25-34:
Second leading cause of death
Peaked in the 1930s at 17.4 per 100,000,
now 10.9 per 100,000.

How big a problem is suicide?
Blister packs for Paracetamol
66% reduction in liver transplant from suicide attempts
Fences at Cornell gorges, Golden Gate Bridge
Restricting access to firearms
But maybe they commit suicide by other means?
So it's important to
assess suicide risk!
How do I do that?
"Do you have suicidal thoughts?"
Social connectedness
Caring for dependent children
Religious beliefs about
suicide
"Intent and Plan"
Suicide is an impulsive, ambivalent act
Please ask! You aren't giving me any ideas I haven't already thought of.
It's all downhill from here....
How do we treat a patient who is acutely suicidal?
(chronically suicidal patient are beyond the scope of this lecture)
SAFETY FIRST = hospitalize
Lethality
Rescue
Attempt hanging in front of spouse
Posting photo of wrist cuts on facebook
Shooting self in woods
Overdosing then going to bed
What if a suicidal patient does not want to be hospitalized?
A "pink slip" can hold a suicidal patient for 72 court hours
Which suicidal patients can go home?
No suicide attempt/gesture (or stabilized s/p attempt)
Lethal means are secured
Able to plan for safety
Identifies protective factors
Family/support is engaged
Modifiable risk factors addressed
Transition to appropriate level of care
Take Home Points
What about risk of violence towards others?
And, what about risk of violence towards others?
How is risk for violence assessed in a medical setting?
Specific target
Often antisocial behavior
Can be planned
Targeted violence
"Are you thinking of hurting others?"

"Do you have a history of becoming violent?"

"How likely are you to lose control and hurt someone?"


Why are patients violent in the hospital?
Watch for signs of agitation
Raised voice
Increased motor/verbal activity
Pacing
Vocalizing threats
What to do when a patient is agitated
Maintain physical distance
Ensure egress route
Get help ("show of force")
Be aware of posture, tone of voice
Validate the emotion
Discover the source of anger
Do not get into a debate
Consider need for meds


No specific target
Acts out of agitation
Impulsive
Unpredictable
vs.
Non-targeted violence
Intoxication or withdrawal
Organic (acute brain injury, postictal)
Delirium
Dementia
Psychosis or mania
Personality disorder
Disruptive personality traits
6) Watch for the agitated patient
1) Suicide is common, and preventable
2) Get the details
3) Means matter: ask about guns.
4) Suicide attempt = hospitalize.
5) Suicidal patients get better.
17.4%
1.7%
21.3%
53.3%
6.3%
(High lethality, high rescue)
(High lethality, low rescue)
(Low lethality, high rescue)
(Low lethality, low rescue)
QUESTIONS?
Full transcript