Download Comprehensive Suicide Risk Assessment

Comprehensive
Suicide Risk Assessment
Andrea Bradford MD MMM
Medical Director, ValueOptions Inc.
Comprehensive Suicide Risk Assessment
 Suicidal ideation and intent only a small part
of the suicide risk assessment
 Factors related to suicide risk frequently
documented in several places and not
included in final formulation of risk
 Modifiable risk factors for suicide frequently
not addressed in treatment plans
 Clinical formulation of suicide risk decreases
potential liability if suicide occurs
Comprehensive Suicide Risk Assessment
 Sources of information other than the patient
important
 Identifying protective factors an important part
of decision making when suicide risk is
present
 A safety contract with respect to suicide is not
an effective tool. It only has validity when the
patient refuses to contract. An agreement to
contract for safety is a potential legal liability
unless it’s importance is discounted in a
formulation
Comprehensive Suicide Risk Assessment
 Having all suicide risk factors and protective
factors co-located for ease of review is
important
 Documenting a suicide risk formulation based
on all risk and protective factors using clinical
judgment is important
 Documenting a treatment plan which is
responsive to potentially modifiable suicide
risk factors is important
Comprehensive Suicide Risk Assessment
Using the Form
 ValueOptions makes available to practitioners
a comprehensive suicide risk assessment
form based on the Catawba Hospital form,
which is copyrighted and used with
permission.
 The form includes predictive risk factors for
completed suicide, protective factors, and
space to identify sources
 The form includes space to document a
formulation of risk and treatment planning
considerations
Comprehensive Suicide Risk Assessment
Using the Form
Patient Name: __________________________
Clinician: ______________________________
Date: _________________________________
Current Mental Status
 Suicidal ideation by consumer
 Suicidal ideation alleged by others
 Realistic plan in community
 Realistic plan in hospital
 Suicidal intent alleged by others
 Suicidal intent expressed by consumer
Comprehensive Suicide Risk Assessment
Using the Form
Clinical Factors
 Severe anxiety and/or agitation
 Anorexia Nervosa
 Bipolar Disorder
 Bipolar II
 Mixed state
 Depressive phase of illness
 Depression
 Severe
 Anhedonia or hopelessness
 Anxiety, agitation, or panic
 Aggression or impulsivity
 Delusional thinking
 Global or partial insomnia
 Recent sense of peace/well-being
 Co-morbid alcohol abuse/dependence
Comprehensive Suicide Risk Assessment
Using the Form
Clinical Factors Continued
 Dysthymia
 Post Partum Depression
 Alcohol/Substance Abuse/Dependence
 Co-morbid Axis I Disorder
 Mixed Drug Abuse Obsessive-Compulsive Disorder
 Schizophrenia
 Paranoid or Undifferentiated Type
 Depressive State
 Command Hallucinations
 More than a high school education
 Less than 40 years old
 Personality Disorders
 Cluster B or Cluster C
 Co-morbid depression
 Co-morbid alcohol abuse/dependence
Comprehensive Suicide Risk Assessment
Using the Form
Clinical Factors Continued
 Epilepsy
 Temporal lobe epilepsy
 Chronic Pain
 More than one psychiatric diagnosis
 Currently psychotic
 Unstable or poor therapeutic relationship
Comprehensive Suicide Risk Assessment
Using the Form
Cognitive Features that Contribute to Risk
 Loss of executive function
 Thought constriction (tunnel vision)
 Polarized thinking
 Closed-mindedness
 Inability to adapt to a dependent role
Comprehensive Suicide Risk Assessment
Using the Form
Loss Factors
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Decrease in vocational status
Loss of significant relationship
Decline in physical health
Loss of freedom due to legal status
Comprehensive Suicide Risk Assessment
Using the Form
Historical Factors
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Prior suicide attempts
Family history of suicide
Anniversary of important loss
Impulsivity
Family of origin violence
Victim of physical or sexual abuse
Domestic partner violence
Comprehensive Suicide Risk Assessment
Using the Form
Demographic Factors
 Male
 65 years or older
 85 years or older
 Low socioeconomic status
 Living alone
 Currently divorced
 Caucasian or Native American
 Unemployed
 Access to/history of use of firearms
 Lack of structured religion
Comprehensive Suicide Risk Assessment
Using the Form
Risk Reduction Factors
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Pregnancy
Responsible for children under 18 years old
Sense of responsibility to family
Catholicism or Judaism is religion of choice
Employed
Living with another person, especially a relative
Positive social support
Positive therapeutic relationship
Comprehensive Suicide Risk Assessment
Using the Form
Individual Risk Reduction Factors and Individual Risk Factors:
For hospitalized consumers, this should include an assessment
of the risk of elopement.
Clinician’s Formulation of Risk: Using the risk factors and risk
reduction factors identified above, describe your estimation of the
consumer’s imminent and long term risk for suicide, as well as
necessary interventions to assure consumer’s safety and facilitate
stabilization. Describe your clinical reasoning in detail.
Interventions: Document interventions which directly address
mitigating those risk factors which are identified and can be
addressed either clinically or with the help of natural supports.
For consumers where a formal crisis plan is developed, that may
serve to complete this section by attaching a copy of that plan.
Using the Form
Case Example
 A 77 year old caucasian male presents to an
outpatient clinic accompanied by his wife of 45 years.
She reports that he threatened to kill himself today.
His history includes a suicide attempt 12 years ago
just prior to his treatment for alcoholism, when his
wife threatened to leave him. He has also been
treated for a major depression 6 and 8 years ago.
His father committed suicide at age 65. His wife
reported that she is moving out today because of his
relapse on alcohol 2 weeks ago. He was diagnosed
with disseminated prostate cancer 2 weeks ago, but
does not want his wife to know. He denies suicidal
ideation or intent. There is a gun in the home.
Using the Form
Case Example 1
Individual Risk Reduction Factors and Individual Risk Factors:
Mr. Patient has serious risk factors to include reported suicide
threats today, a history of a prior attempt, a family history of
suicide, alcohol dependence with a recent relapse, and a history
of major depressive episodes. His wife is leaving him and he
has recently been diagnosed with cancer. He is a caucasian
male in a high risk age group and also has access to a gun. He
has no identified risk reduction factors.
Using the Form
Case Example 1
Clinician’s Formulation of Risk: Using the risk factors and risk
reduction factors identified above, describe your estimation of
the consumer’s imminent and long term risk for suicide, as well
as necessary interventions to assure consumer’s safety and
facilitate stabilization. Describe your clinical reasoning in detail
Despite his reports that he is having no suicidal thoughts, Mr.
Patient is considered to be at high risk for suicide due to the
severity and multiplicity of his risk factors. At his age, either his
wife leaving or his medical condition would place him at serious
risk if a threat were voiced (as he did, per his wife’s report), but
his additional risk factors increase his risk to the point that he
needs immediate hospitalization to further assess his
depression and plan for risk reduction.
Using the Form
Case Example 1
Interventions: Document interventions which directly address
mitigating those risk factors which are identified and can be
addressed either clinically or with the help of natural supports.
For consumers where a formal crisis plan is developed, that
may serve to complete this section by attaching a copy of that
plan.
Mr. Patient will be hospitalized immediately. His wife has agreed to
participate in therapy sessions while he is hospitalized, where
he will be encouraged to share his medical condition with her.
Additional supports in his community and social network will be
enlisted, including collaboration with his family doctor. His
current depressive symptoms and alcohol use will be
addressed, and outpatient appropriate outpatient resources
identified. His wife has agreed to remove the gun.
Using the Form
Case Example 2
Ms Disorder is a 32 year old female who presents for her regular
therapy appointment complaining that she just can’t go on. She
has three children ages 8, 10 and 14 and has been living with
her mother for the past 12 years. She has been treated for
Borderline Personality Disorder for the past 10 years, and her
symptoms include intermittent suicidality, mild psychotic
symptoms, cutting on her arms, and frequent family fights. She
is currently reporting no psychotic symptoms, but feels she will
never “get ahead” and be able to live independently. She has
never previously attempted suicide and there is no family history
of suicide or abuse. She has never been married, but does
have a current boyfriend. Her family is active in the Catholic
church. She reports that she is thinking about “ending it all” by
taking all of her medications.
Using the Form
Case Example 2
Individual Risk Reduction Factors and Individual Risk Factors:
Ms Disorder has risk factors to include her Personality Disorder, her
current suicidal ideation and her impulsivity. Her protective
factors include her responsibility for her 3 children, her religion,
the fact that she lives with her mother, the support she gets from
her boyfriend and her long standing therapy relationship.
Using the Form
Case Example 2
Clinician’s Formulation of Risk: Using the risk factors and risk
reduction factors identified above, describe your estimation of
the consumer’s imminent and long term risk for suicide, as well
as necessary interventions to assure consumer’s safety and
facilitate stabilization. Describe your clinical reasoning in detail
Based on the risk factors and risk reduction factors above, and
drawing on my 4 year treatment relationship with Ms Disorder, in
my clinical judgment, her risk for suicide remains low. She has
never attempted suicide, despite episodes of suicidality
expressed with more vigor than the current report. Her mother
is involved in her treatment and will be engaged to watch her
daughter more closely. Ms Disorder is also very engaged with
her religion and children and will not engage in behavior she
sees as potentially hurtful to them.
Using the Form
Case Example 2
Interventions: Document interventions which directly address mitigating
those risk factors which are identified and can be addressed either
clinically or with the help of natural supports. For consumers where a
formal crisis plan is developed, that may serve to complete this section
by attaching a copy of that plan
With permission, Ms Disorder’s mother has been contacted and will
talk with her and watch for any signs of escalation. Ms Disorder
has agreed to keep her appointment this evening with her priest
and has been reminded of her access to the emergency
services in her area. She will be enrolled in a DBT group which
starts next week to deal with her thoughts of self harm. Her
therapy appointments with me will continue to focus on her
following through on positive actions in her life and actively
managing her symptoms. A peer counselor has been identified
who has overcome similar problems.