Overview • Malpractice issues Suicide Risk Assessment and Malpractice Prevention • Suicide risk factors • Suicide assessment • Suicide in diagnoses Phillip J. Resnick, MD • Video exercise Professor of Psychiatry Case Western Reserve University Cleveland, Ohio Malpractice Standard Malpractice Issues A clinician is required to exercise that reasonable degree of knowledge and skill which is ordinarily possessed by other members of his profession in similar circumstances. Simon RI. Therapeutic Risk Management of the Suicidal Patient. In: Simon RI, et al (Eds). Textbook of Suicide Assessment and Management . Second Edition. Arlington, VA: American Psychiatric Publishing; 2012. Clinician Errors • Errors of Fact – failure to obtain Risk Factors for Suicide relevant data • Errors of Judgment – act in good faith after exercising requisite care Tsao CI, et al. Compr Psychiatry . 2007;48(4):309-312.
Risk Factor Classification Static Risk Factors Dynamic • Male > Female — subject to change by • White > Black intervention • Teenagers and men > 60 Static — not subject to change • Unmarried by intervention Work Group on Suicidal Behaviors. Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. November 2003. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. Accessed April 17, 2017. Static Risk Factors Dynamic Risk Factors • Past suicide attempts • Current suicidal thoughts • Family history of suicide • Current psychiatric illness • Chronic medical illness • Substance abuse • Unemployment Work Group on Suicidal Behaviors. Practice Guideline for the Assessment and Treatment of Patients Work Group on Suicidal Behaviors. Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. November 2003. with Suicidal Behaviors. November 2003. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. Accessed April 17, 2017. Accessed April 17, 2017. Dynamic Risk Factors Acute Risk Factors • Feelings of hopelessness • Severe psychic anxiety • Lack of social support • Anxious ruminations • Life crises • Global insomnia – Rejection • Recent alcohol use – Fall in status Work Group on Suicidal Behaviors. Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. November 2003. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. Accessed April 17, 2017. Fawcett J. Diagnosis, Treatment, and Management of Suicide. Primary Psychiatry . 2005;232-234.
Acute Risk Factors Comorbidity and Suicide • Severe psychic anxiety • Depression predicts suicidal ideas • Anxious ruminations • Anxiety and poor impulse control predict suicide attempts • Global insomnia • Recent alcohol use Fawcett J. Diagnosis, Treatment, and Management of Suicide. Primary Psychiatry . 2005;232-234. Nock MK, et al. Mol Psychiatry . 2010;15(8):868-876. Suicide Ladder Wish you were dead? Assessment of Suicidality Suicidal thoughts? Suicidal method? Suicidal intent? How close have you come? Simon RI. Therapeutic Risk Management of the Suicidal Patient. In: Simon RI, et al (Eds). Textbook of Suicide Assessment and Management . Second Edition. Arlington, VA: American Psychiatric Publishing; 2012. Suicide Ladder Aborted Attempts Wish you were dead? • Intent to die Suicidal thoughts? • Change of mind immediately before attempt Suicidal method? • Absence of injury Suicidal intent? • Associated with actual attempts How close have you come? Simon RI. Therapeutic Risk Management of the Suicidal Patient. In: Simon RI, et al (Eds). Textbook of Suicide Assessment and Management . Second Edition. Arlington, VA: American Psychiatric Jobes DA. Managing Suicidal Risk: A Collaborative Approach . Second Edition. New York, NY: Guilford Publishing; 2012. Press; 2016.
Cumulative Probabilities Near Lethal Attempts Suicidal 34% suicidal plan Suicidal ideas began: ideas 26% unplanned • 24% within 5 minutes attempt • 70% within 1 hour Suicidal plan 72% suicide attempt Levin A. Understanding Access to Means of Suicide Opens Doors to Prevention. Psychiatric News . Kessler RC, et al. Arch Gen Psychiatry . 1999;56(7):617-624. 2015;50(2):9, 29. Protective Factors Protective Factors • Responsibility to family • Pregnancy • Fear of the actual act • Positive coping skills • Fear of the unknown • Positive social support • Fear of social disapproval • Positive therapeutic relationship • Religious belief it is wrong US Public Health Service. The Surgeon General’s Call to Action to Prevent Suicide . Washington DC: US Public Health Service. The Surgeon General’s Call to Action to Prevent Suicide . Washington DC: 1999:8-10. https://profiles.nlm.nih.gov/ps/access/nnbbbh.pdf. Accessed April 17, 2017. 1999:8-10. https://profiles.nlm.nih.gov/ps/access/nnbbbh.pdf. Accessed April 17, 2017. Protective Factors Path to Suicide • Pregnancy • Suicidal idea • Positive coping skills • Suicidal plan • Positive social support • Suicidal preparation • Positive therapeutic • Suicidal rehearsal relationship • Suicidal act US Public Health Service. The Surgeon General’s Call to Action to Prevent Suicide . Washington DC: 1999:8-10. https://profiles.nlm.nih.gov/ps/access/nnbbbh.pdf. Accessed April 17, 2017. Chu C, et al. J Clin Psychol . 2015;71(12):1186-1200.
Suicidal Plan • Specificity of plan Meaning of Death • Availability of lethal method • Actual preparation Jobes DA. Managing Suicidal Risk: A Collaborative Approach . Second Edition. New York, NY: Guilford Press; 2016. Suicide Attempt Assessment Patient’s Report • Isolation and timing • Intent and expectations • Acting to get help • Relationship to substances and stressors • Final acts, eg, will • Aborted attempts • Suicide notes Simon RI. Therapeutic Risk Management of the Suicidal Patient. In: Simon RI, et al (Eds). Textbook of Simon RI. Therapeutic Risk Management of the Suicidal Patient. In: Simon RI, et al (Eds). Textbook of Suicide Assessment and Management . Second Edition. Arlington, VA: American Psychiatric Suicide Assessment and Management . Second Edition. Arlington, VA: American Psychiatric Publishing; 2012. Publishing; 2012. Suicide Risk Assessment Suicide Assessment • Statements about suicidality Although Mr. Jones denies any suicidal • Past suicide attempts ideas, his risk is moderate due to his • Hopelessness history of 2 past suicide attempts, • Psychotic symptoms severe depression with delusions, and acute anxiety. Shea SC. Suicide Assessment Part 1: Uncovering Suicidal Intent—A Sophisticated Art. Psychiatric Times. December 3, 2009.
Suicide Risk Although Mr. Smith reports suicidal ideas, they are no worse than they • Minimal have been intermittently for the last 3 • Moderate years. Furthermore, suicide risk is low • Severe because of no prior attempts, no access to firearms, a future orientation, and a strong therapeutic relationship. No-Suicide Contracts Losses in Suicide • False sense of security • Life • Significant if refused • Family • Need for working alliance • Future • Significance of prior violations • Risk of eternal damnation • Stigmatization of children Simon RI. Therapeutic Risk Management of the Suicidal Patient. In: Simon RI, et al (Eds). Textbook of Suicide Assessment and Management . Second Edition. Arlington, VA: American Psychiatric Publishing; 2012. Emotions Evoked in Family by Suicide Inpatient Suicide • Anger • 6% of US suicides • Sadness • 78% denied suicidal ideas • Betrayal • 51% were on q 15 min checks • Guilt • High risk shortly after discharge Jabbarpour YM, et al. Focus . 2011;9(2):186-193. Busch KA, et al. J Clin Psychiatry . 2003;64(1):14-19.
Attitude Toward Therapist Adversaries • The patient’s goal is to die by suicide • Ally — desire to live • The therapist’s goal is to prevent the • Adversary — after decision to die suicide Resnick PJ. Recognizing that the Suicidal Patient Views You as an Adversary. Current Psychiatry . Resnick PJ. Recognizing that the Suicidal Patient Views You as an Adversary. Current Psychiatry . 2002;1(1):8. 2002;1(1):8. Patient Question Implications • Do not accept disavowal of suicidal plans at face value Why would I tell you I had a suicidal • Look for objective signs of plan if I really wanted to kill myself? improvement • Involve family in treatment Tell Relatives to Report Final Suicidal Goodbyes • Talk of suicide • 60% to spouses • Talk of giving up • 50% to relatives • Putting affairs in order • 18% to therapists • Final goodbyes • Acquiring a weapon Robins E, et al. Am J Psychiatry . 1959;115(8):724-733.
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