SUICIDAL BEHAVIORS IN CLINICAL HIGH-RISK POPULATIONS Shirley Yen, Ph.D. Associate Professor Department of Psychiatry Beth Israel Deaconess Medical Center, Harvard Medical School
OBJECTIVES •Review evidence for increased risk of suicidal behavior in those who experience psychosis symptoms. •Review basics of a suicide risk assessment. •Provide overview of intervention strategies to reduce suicidal behavior, with a specific focus on Safety Planning Intervention. •Clinical vignettes to illustrate intervention for suicidal behaviors. 2
Suicidal Behaviors in Adolescents with Psychosis-like (CHR) Symptoms • In a prospective study of 1112 school aged adolescents in Ireland, part of the Saving and Empowering Young Lives in Europe (SEYLE) study, 7% of adolescents endorsed psychotic symptoms. (Kellerer et al., 2013; JAMA Psychiatry). • Those endorsing psychotic symptoms have an estimated 10- fold increased odds of any suicidal behavior. • Those with comorbid depression have a 14-fold increased odds of suicide plans or acts compared to depressed non- psychotic youths. • Those with suicidal ideation have a 20-fold increased odds of suicide plans or acts compared to adolescents without psychotic symptoms. • 70-fold increased odds of an acute suicide attempt. 3
Increased Risk of Suicide After FEP • After two years of follow-up, 12.4% attempted suicide (Sanchez-Gistau et al., 2012) . • After four years of follow-up, 18% attempted suicide and 3% died by suicide (Clarke et al., 2006 ). • Suicide rate is 11x higher in patients with early psychosis compared to the general population in the year after initial contact, 7x higher five years later, 4x higher ten years later. Median time to suicide was 5.4 years (Dutta et al., 2010) . • Risk appears to diminish over time, though still elevated compared to general population. 4
Diagnostically agnostic • Collaborative Psychiatric Epidemiology Surveys (N = 11,716); (DeVylder et al., 2014 JAMA Psychiatry) • Psychosis symptoms -> higher SI (5x) and SA (9x) • Most with psychosis (65%) also met criteria for depression, anxiety, or substance use disorder. • Cohort study in Sweden of hospitalized patients with FEP (N = 2819) (Bjorkenstam et al., 2014 Schizophrenia Res) • Overall, 121 patients (4.3%) died by suicide. • The highest suicide rates were found in depressive disorder with psychotic symptoms and in delusional disorder. 5
Hallucinations and Delusions • In the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE; N = 1460), positive symptoms of psychosis (hallucinations and delusions) were found to exacerbate the relationship between symptoms of depression and suicide ideation. ( Bornheimer et al., 2016 ) • In several prospective follow-up studies of early psychosis, patients with hallucinations were at significantly greater risk of attempting suicide (Connell et al, 2016) , developing suicidal tendencies (Madsen et al., 2012) and more likely to die by suicide (Upthegrove et al., 2010) . 6
Suicide is Not Predictable • There are numerous risk factors and warning signs (please refer to https://afsp.org/about-suicide/risk-factors- and-warning-signs/ as a reference). • There is no typical suicide victim. • In a study of 4,800 hospitalized vets, it was not possible to identify who would die by suicide — too many false- negatives, false-positives. • Individuals of all races, creeds, incomes and educational levels die by suicide. Individuals who engage in suicidal behavior are extremely heterogeneous American Foundation for Suicide Prevention
Suicide Communications Are Often Not Made to Professionals • In one psychological autopsy study, only 18% told professionals of intentions (Robins et al., Am J Psychiatry, 1959) • In a study of suicidal deaths in hospitals: • 77% denied intent on last communication • 28% had “ no suicide ” contracts with their caregivers (Busch et al., J Clin Psychiatry, 2003) • Research does not support the use of no-harm contracts (NHC) as a method of preventing suicide, nor from protecting clinicians from malpractice litigation in the event of a client suicide (Lewis, SLTB 2007) American Foundation for Suicide Prevention
Suicide Communications ARE Made to Others • Importance of Gatekeepers, Family, Friends • In adolescents, 50% communicated their intent to family members (Robins et al., Am J Psychiatry, 1959) • In elderly, 58% communicated their intent to the primary care doctor (Busch et al., J Clin Psychiatry, 2003) American Foundation for Suicide Prevention
Gatekeeper Tools • QPR (Question, Persuade, Refer) • https://qprinstitute.com/ • Suicide Screens • Patient Health Questionnaire (PHQ-9) • Ask Suicide-Screening Questions (ASQ) Toolkit https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq- toolkit-materials/index.shtml • Patient Safety Screener 3 (PSS-3) http://www.sprc.org/micro- learning/patientsafetyscreener • Don’t approach like a checklist; be empathic and genuine. • Be extremely judicious in using hospitalization as a deterrent. 10
Means Restriction • Many suicide attempts occur with little planning, particularly in young people • Intent is usually ambivalent: • “ I instantly realized that everything in my life that I’d thought was unfixable was totally fixable – except for having just jumped .” (Golden Gate bridge survivor, New Yorker, 2003) • Suicide rates much higher in states that have the least gun restriction laws • Firearms used in suicides by young people usually belong to parents • Blister packs reduced suicide death by Tylenol by 43% after Britain changed their packaging requirements. • Reducing means saves lives 11
Suicide Death by Method 12
Clinician: Suicide Risk Assessments • To gain a more comprehensive understanding: • Columbia Suicide Severity Rating Scale (C-SSRS) • http://cssrs.columbia.edu/ • Suicide Assessment Five-step Evaluation and Triage (SAFE-T): • https://store.samhsa.gov/product/SAFE-T-Pocket-Card-Suicide- Assessment-Five-Step-Evaluation-and-Triage-for-Clinicians/sma09- 4432 • Collaborative Assessment and Management of Suicidality (CAMS) • https://cams-care.com/about-cams/ 13
Suicide Risk Assessment Basics • Therapeutic alliance is key. Collaborative, compassionate, authentic • Ideation : How often do you find yourself thinking about suicide? How long have you been feeling this way? • Intent : How strong is the urge to suicide? Do you intend to act on your suicidal thoughts? (If unknown, past history of attempts). • Plan : Do you have a specific plan? What is your plan? Have you been mentally rehearsing this plan? • Means : Do you have what you need to carry out your plan? Do you have access to firearms? What about substances? Large quantities of medications? • Protective Factors : What are some things that have kept you alive? What do you value? What’s important to you? 14
Suicide Prevention Interventions • Safety Planning Intervention (SPI) • Dialectical Behavior Therapy (DBT) • Collaborative Assessment and Management of Suicidality (CAMS) • Coping Long Term with Attempted Suicide (CLASP) 15
Safety Planning Intervention (SPI) • One-session evidence-based intervention • Does not replace any longer-term treatment • 25-45 minutes • Incorporates evidence-based risk reduction strategies: • teaching brief problem solving and coping skills • enhancing social support and identifying emergency contacts • means restriction • motivation for additional treatment Stanley & Brown, Cognitive and Behavioral Practice, 2012 Stanley et al., JAMA Psychiatry, 2018 16
Clinical Context • Risk assessment / individual’s story • Rationale for Safety Planning • Creation of Safety Plan • Reasons for Living • Plan for how safety plan will be used • Future visits: review and revise as needed 17
Risk Assessment / Individual’s Story • Have the individual feel heard; build alliance with patient • Understand clinical context • Set up the expectation that this will be a collaborative process • Listen for information you may then use in the safety plan 18
Rationale for Safety Planning Danger of acting on suicidal feelings RISK TIME 19
Safety Plan Overview: 6 Steps 1. Recognizing warning signs 2. Using internal coping strategies that clients can do on their own 3. Using social supports & environment to distract-- socializing with people or going to social/public places 4. Contacting family/friends and asking for assistance 5. Contacting mental health professionals/agencies 6. Make the environment safe. 20
Step 1: Warning Signs • Present rationale • Need to know when to use the safety plan • How will you know that you need to look at your safety plan? • What do you experience right before you begin to think about suicide? • Get specific • Command hallucinations ( voice telling me to kill mysel f) • Thoughts or images ( traumatic flashback ) • Emotions ( sad, tearful, angry, down on myself ) • Behaviors ( increased urge to smoke MJ, poor sleep ) • Physical sensations ( increased agitation, need to pace ) • External cues or events ( near X bridge ) 21
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