is your patient at risk of suicide? by orman
TRANSCRIPT
Is my patient suicidal?
Rob Orman, MD
What to say
What to ask
Knowledge Gap
Knowledge Absence
Good
Bad
Rare
Complete suicide
3% high risk
60% low risk
Lie
LieSelf
Reported
The Suicide Thromboelastograph
Friends and
Family
Friends and
FamilyKnow
What is suicidal ideation?
Mindset and
Intent
Suicide attempt
Suicide attempt
Stress relief
Suicide attempt
Stress reliefattention
What and Why
Mindset and
Intent
Injury is secondary
Why did it happen?
What
WhatWhen
WhatWhen
Why
What
Why
Mindset and
Intent
Is this suicidal ideation?
What
Why
What
WhyStressedRelieves Tension
Is this suicidal ideation?
What
Why
What
WhyHopelessDepressedNo way out
Is this suicidal ideation?
Behavior
Behavior
Motivation
Behavior
Motivation
What
Why
What
Why
Takes away the pain
Do you feel suicidal?
Do you feel suicidal?
Always!
What
Chronic ideation
What
WhyGet the story
What
WhyRisk Assess
How to assess suicide risk?
Gestalt
Gestalt
Decis
ion tools
Gestalt
Decis
ion tools
Spontaneous questions
Organized
Organized
Systematic
Columbia Suicide Severity Rating
Scale
What questions to ask
How to ask
Structure interview
6 questions
Doesn't Have
to be the patient
6 questions
Is there ideation?
Have you ever wished you were dead or
wished you could go to sleep and not wake
up?
Have you ever had thoughts of killing
yourself?
No?
Have you ever wished you were dead or
wished you could go to sleep and not wake
up?
Have you ever had thoughts of killing
yourself?
No?
No ideation
Have you ever done anything, started to do anything, or prepared to do anything to end
your life?
Yes ideation
Define it
Vague thoughts
Vague thoughts
Specific Plan
Define the
ideation
Is there INTENT
Have you been thinking about how you might
kill yourself?
Have you had these thoughts and had some intention of acting on
them?
Is there INTENT
with a plan
Have you started to work out the details
of how to kill yourself? Do you
intend to carry out the plan?
Have you ever done anything, started to do anything, or prepared to do anything to end
your life?
Obvious
What did you think would happen when
y0u did X?
How do you feel now that you’re not dead?
Explore the
ideation
Incessant or
fleeting
Previous attempts
What’s stopping
you?
Protective Factors
Did you want to kill
yourself?
Did part of you want to kill yourself?
ideation
ideationintent
ideationintentplanning
inform
inform
suicide risk
Organized Systematic
What
Why
Mindset and
Intent
Impulsive Act
Short Lived
hopelessness
hopelessnesstrapped
hopelessnesstrapped
previous
hopelessnesstrapped
previousideation
Remove the
Means
1-2%
1-2%
61%
1-2%
61%
82%
Remove the
Means
Chance of Dying
Lower
40%
Remove the
Means
Chance of Dying
Lower
ASK
What
WhyGet the story
What
Why
Mindset and
Intent
Risk Assessment
Is there ideation?
Explore the
ideation
Gestalt
Gestalt
Decis
ion tools
Gestalt
Decis
ion tools
Spontaneous questions
The what
Thinking about OD
The why
Breakup
BreakupLost Job
BreakupLost JobDepressed
20yo
20yothinking
20yothinking
OD
20yothinking
OD
mult triggers
What
Why
What
Why
Is there ideation?
Have you ever wished you were dead or
wished you could go to sleep and not wake
up?
Yes
Have you ever had thoughts of killing
yourself?
Tonight
Yes ideation
Is there INTENT
Have you been thinking about how you might
kill yourself?
OD
Have you had these thoughts and had some intention of acting on
them?
Yes
Have you started to work out the details
of how to kill yourself? Do you
intend to carry out the plan?
Lock self in bathroom
Lock self in bathroom
family asleep
Have you ever done anything, started to do anything, or prepared to do anything to end
your life?
Not before tonight
Explore the
ideation
Incessant or
fleeting
Previous attempts
What did you think would happen when
y0u did X?
How do you feel now that you’re not dead?
What’s stopping
you?
Fear
Trivial
TrivialLife threat
Never Perfect
Never PerfectAlways Excellent