Suicide Risk Assessment and Documentation

Thad Q. Strom, Ph.D.Minneapolis VAMC

AcknowledgmentsThank you to Drs. Michael, Anestis, and

Siegel for input and guidance on the following slides.

ObjectivesFollowing this presentation, participants will

be able to:Discuss sociocultural factors that impact

suicide assessment within the VADescribe the concepts of the Interpersonal

Psychological Theory of suicidal behaviorDescribe risk factors for suicideSuccessfully assess and document suicide risk

level

AgendaBrief discussion of interaction between VA

related suicide, the media, politics and clinical care.

Overview of the Interpersonal-Psychological Theory of Suicidal Behavior

Review of a framework for determining suicide risk level

Briefly review documentation and VA suicide prevention initiatives

Suicide34,000 US deaths annually

1 every 16 minutesApproximately 93 per dayApproximately 20% are veterans (April 2010, DVA Fact Sheet)

11th leading cause of death in US8th for males (19 per 100,000)16th for females (5 per 100,000)2nd leading cause of death in college students (3rd for age

10-24)More common than death by homicide8.5-25 attempts for every death by suicide

Approximately 5,000,000 individuals in US have attempted

CDC, 2007

SuicideSex differences

Men substantially more likely to die by suicide than women White males over 65 years of age at greatest risk

Women three times more likely to attempt 67% of male suicide deaths by firearms; 33% for women

CDC, 2007

What do you assess for suicide risk?What have you learned to assess for thus far

in your career?

Why have you been told it is important to assess these things?

Interpersonal-Psychological Theory of Suicidal Behavior (IPTS)

Thwarted Belongingness

Capability for Suicide

1. Perceived Burdensomeness• Makes no valuable contributions to world

2. Thwarted Belongingness• Has no meaningful connections to others

3. Acquired Capability for Suicide• Habituation to physiological pain and fear of death

Desire for

Suicide

Joiner, 2005

Perceived Burdensomen

ess

Lethal (or near lethal)

Suicide Attempts

IPTS – Empirical SupportBurdensomeness * Belongingness

Suicidal Ideation (Joiner et al., 2009; Van Orden et al., 2008)

Acquired Capability for Suicide associated with… Lifetime number of painful and provocative events (Van Orden et

al., 2008)

Lifetime number of suicide attempts (Van Orden et al., 2008)

Range of combat experiences encountered by military personnel deployed in Operation Iraqi Freedom (Bryan et al., 2010)

PTSD re-experiencing symptoms (Bryan & Anestis, in press)

Higher in military samples than in civilian clinical and non-clinical samples (Bryan, Anestis, Morrow, & Joiner, 2010; Selby, Anestis, et al., 2010)

3-way interaction of IPTS Components Clinician-rated suicide risk (Joiner et al., 2009)

Lifetime number of suicide attempts (Van Orden et al., 2008)

Adapted from a slide from Michael Anestis

Determining Risk: A FrameworkSeven domains of risk factors have been

proposed:Previous suicidal behaviorNature of current suicidal symptomsPrecipitant stressorsGeneral symptomatic presentationPresence of hopelessnessImpulsivity and self-controlOther predispositionsProtective factors

Joiner, Walker, Rudd, & Jobes, 1999

Previous Suicidal BehaviorThe most important domain for risk

assessmentSome evidence of important differences

between: Suicide ideators Single attempters Multiple attempters

For multiple attempters, the baseline risk will always be elevated.

History of attempts is always evaluated in conjunction with other risk domains.

Nature of Current Suicidal SymptomsDivided into two factors:

Resolved plans and preparation Ex: Feeling competent and courageous to make

attempt, availability of means and opportunity, duration and intensity of ideation.

Suicidal desire and ideation Ex: Reasons for living, wish to die, frequency of SI,

talk of death and/or suicide.

While frequency of SI is noteworthy, intensity and duration of SI is a more pernicious indicator.

Precipitant StressorsImportant to assess for recent life stressorsParticularly those involving interpersonal loss

and disruptionEx: relationship disruption, legal troubles,

physical/emotional abuseAttempt history tends to affect the duration

of suicidal symptoms following crisis. Even non-attempters may develop SI in the face of

life crises, but the duration of this crisis is likely to be shorter.

Risk Factors (cont’d)General Symptomatic Presentation

Including HopelessnessReview the presence and severity of Axis I and

Axis II symptomatology.Perhaps the most commonly reviewed through

grad school trainingImpulsivity and Self-Control

Impulsivity tends to be a trait factor that is present throughout a person’s life

Other Pre-disposing factorsChaotic childhood, sexual/physical abuse

Protective FactorsSocial support

Self-perceived quality of social supportSelf- control and problem-solving ability

These do not negate serious risk factors (e.g., multiple attempts) but may help determine level between categories.

Determining Risk: A ContinuumPresence of multiple attempts in conjunction

with other risk factors determines severity.Severity Ratings:

Non-existent No identifiable suicidal symptoms, no past history,

and no or few other risk factorsMild

Multiple attempter with no other risk factors, OR A nonmultiple attempter with SI of limited intensity

and duration, and No or mild planning/resolution, and No or few other risk factors

Joiner, Walker, Rudd, & Jobes, 1999

Determining Risk: A ContinuumModerate

A multiple attempter with any other notable finding, OR

A non-multiple attempter with severe to moderate preparation and resolution

SevereMultiple attempter with any two or more

notable findingsNon-multiple attempters with significant

preparation/plans and at least one other risk factor

Extreme

Graphic RepresentationMultiple

Attempter?

Yes No

Resolved Plans &

Preparation?

Any other significant risk

factor = AT LEAST Moderate Risk

Yes No

Any other significant risk

factor = AT LEAST Moderate Risk

Suicidal Desire & Ideation?

NoYes

Two or more other significant risk

factor = AT LEAST Moderate Risk

Joiner, Walker, Rudd, & Jobes, 1999

DocumentationProgress notesNo-show/cancellation notesRisk FlagsSuicide behavior reportsSafety Plans

Standard disclaimer: If the risk assessment or outreach is not documented, then it is considered to never have happened!

No-shows and Cancellations Consider outreach on a continuum:

Do nothing Send a letter (Try to) call the veteran (Try to) call individuals for whom there is a signed

release of information Contact the sheriff’s department to arrange for a

welfare check Consider the potential effects of outreach

attempts on the treatment and the therapeutic relationship

Generally better to err on the side of higher-level outreach

Suicide Behavior ReportNecessary documentation when an attempt

has been made, or there is a clinically relevant increase in risk for someone who has had a suicide behavior report noted previously.

Reviewed and tracked by suicide prevention coordinator

May lead to a suicide behavior flag in the veteran’s chart.

Suicide and the Media

VA Campaigns to Reduce SuicideSuicide Prevention Coordinatorshttp://www.mentalhealth.va.gov/suicide_prev

ention/

Suicide Risk Flag in CPRS

Our Local FacilityLet’s discuss some risk management

procedures locally.

Links• Military Suicide Research Consortium

• https://msrc.fsu.edu/• Psychotherapy Brown Bag

• www.psychoterapybrownbag.com• National Institute of Mental Health• www.nimh.nih.gov

• Substance Abuse and Mental Health Services Administration (SAMHSA)• www.samhsa.gov • National suicide prevention number: 1-800-273-TALK

• Suicide Prevention Resource Center• www.sprc.org