Assessing Risk for Suicide
in the Primary Care Setting
Presented by: Jonathan Betlinski, MD
Date: 10/02/2014
Disclosures and Learning Objectives
• Learning Objectives
–
–
–
–
Know the five steps of Suicide
Assessment
Know at least three screening tools
Know ORS as it relates to involuntary
holds placed outside hospitals
Know at least two numbers to call
Disclosures: Dr. Jonathan Betlinski has nothing to disclose.
Assessing for Risk of Suicide
• Review risk factors for suicide
• Review SAFE-T and other screening tools
• Reminder of legal responsibility
• Next Week's Topic
Risk Factors for Suicide
Suicide is the 10th leading cause of death
–
2nd in age 25-34, 3rd in age 15-24
Suicide rate is 17.6 per 100,000 people
–
The rate increased 30% from 1999 to 2010
Having a mood disorder increases risk 20x
–
–
–
Mood disorders account for 50%
Schizophrenia accounts for 14%
Personality Disorders account for 14%
http://www.nytimes.com/2013/05/03/health/suicide-rate-rises-sharply-in-us.html?_r=0
http://books.google.ca/books?id=fV8_1u0c7l0C&pg=PA31#v=onepage&q&f=false
More Risk Factors for Suicide
•
•
8.6% lifetime risk for psychiatric
inpatients
20% of those who die have a prior
attempt
–
–
•
•
•
1% of attempts will die within one year
5% of attempts will die in 10 years
25-40% got any MH services last year
20% saw an MHP in the last month
45% saw their PCP in the last month
Suicide and Firearms
•
•
•
•
People who have access to a firearm are
three times more likely to commit suicide
Men with home access to a firearm are four
times more likely than women to commit
suicide with a firearm
Men with home access to a firearm are ten
times more likely to die by suicide with a
firearm then men with no home access
Attempting suicide with a firearm results in
death 90% of the time
http://annals.org/article.aspx?articleid=1814426
http://www.mentalhelp.net/poc/view_index.php?idx=119&d=1&w=5&e=28649
SAFE-T (Suicide Assessment Five-step
Evaluation and Triage)
•
Identify Risk Factors
–
•
Identify Protective Factors
–
•
•
•
Note those that can be modified
Note those that can be enhanced
Conduct Suicide Inquiry
Determine Risk Level/Intervention
Document
http://www.integration.samhsa.gov/images/res/SAFE_T.pdf
Identify Risk Factors
Ideation – threatened or communicated
Substance abuse – excessive or increased
Purposeless – no reason for living
Anxiety – agitation/insomnia
Trapped – feeling there is no way out
Hopelessness
Withdrawing – from friends/family/society
Anger (uncontrolled) – Rage, seeking Revenge
Recklessness – risky acts, unthinking
Mood Changes (dramatic)
http://store.samhsa.gov/shin/content//SVP06-0153/SVP06-0153.pdf
Identify Protective Factors
•
•
Internal
–
Sense of responsibility
–
Life satisfaction
–
Positive Coping and Problems-solving Skills
–
Reality Testing Ability
External
–
Children in the home and/or pregnancy
–
Religiosity
–
Positive Social Support
–
Positive Therapeutic Relationship
http://www.integration.samhsa.gov/images/res/SAFE_T.pdf
http://psychiatryonline.org/content.aspx?bookID=28&sectionID=1673332#56073
Conduct Suicide Inquiry
•
Ask the person directly if he or she
–
–
–
•
•
•
Is having suicidal thoughts/ideas
Has a plan to do so
Has access to lethal means
“Are you thinking about killing yourself?”
“Have you thought of ways that you
might hurt yourself?”
Asking does not increase risk!
http://store.samhsa.gov/shin/content//SVP06-0153/SVP06-0153.pdf
Determine Risk Level / Intervention
•
NSW Risk Assessment Guide
–
•
CSUS Suicide Risk Assessment
–
•
http://www.acponline.org/acp_press/essentials/cdim_ch30_wed05.pdf
Harvard Risk Management Guidelines
–
•
http://www.csus.edu/indiv/b/brocks/Workshops/District/2.Suicide%20Risk%20Assessment%20Su
mmary.pdf
ACP Assessment of Suicidal Ideation
–
•
http://www0.health.nsw.gov.au/pubs/2004/pdf/community_mental_hlt.pdf
https://www.rmf.harvard.edu/GuidelinesAlgorithms/2011/~/media/Files/_Global/KC/PDFs/suicideAs
SAMHSA Grid
–
http://www.integration.samhsa.gov/images/res/SAFE_T.pdf
Determination of Risk / Intervention
•
•
•
•
•
•
BHS – ED
MHTS
MSHR
ReACT Self
Harm Rule
Beck's SIS
DSI – SS
http://www.guideline.gov/content.aspx?id=47355
•
•
•
•
•
•
•
GDS
RAM
SIQ
SIQ – JR
VASA
NGASR
RSQ
Now What?
•
•
Do not leave the person unattended
Call County Crisis Line or 800.273.TALK
–
–
–
•
•
Clackamas 503.655.8585
Multnomah 503.988.4888
Washington 503291.9111
Arrange for transport to the nearest
available hospital for evaluation
“Safety contracts” don't prevent suicide
http://store.samhsa.gov/shin/content//SVP06-0153/SVP06-0153.pdf
Legal – ORS 426.231
•
(1) A physician licensed by the Oregon Medical Board
may hold a person for transportation to a treatment
facility for up to 12 hours in a health care facility
licensed under ORS chapter 441 and approved by the
Oregon Health Authority if:
–
(a) The physician believes the person is dangerous
to self or to any other person and is in need of
emergency care or treatment for mental illness;
–
(b) The physician is not related to the person by
blood or marriage; and
–
(c) An admitting physician at the receiving facility
consents to the transporting.
http://www.oregonlaws.org/ors/426.231
Legal, Part II – ORS 426.231, Continued
•
•
(2) Before transporting the person, the physician
shall prepare a written statement that:
–
(a) The physician has examined the person within
the preceding 12 hours;
–
(b) An admitting physician at the receiving facility
has consented to the transporting of the person for
examination and admission if appropriate; and
–
(c) The physician believes the person is dangerous
to self or to any other person and is in need of
emergency care or treatment for mental illness.
(3) The written statement required by subsection (2) of this section authorizes a peace officer, an individual
authorized under ORS 426.233 (Authority of community mental health program director and of other
individuals) or the designee of a community mental health program director to transport a person to the
treatment facility indicated on the statement. [1993 c.484 §3; 1997 c.531 §3; 2009 c.595 §403; 2013 c.360
§39]
http://www.oregonlaws.org/ors/426.231
Summary
•
•
•
•
•
•
•
Suicide rates are increasing
Most people with SI do not die by suicide
The best get it right only 70% of the time
Best strategy is to be gentle and direct,
AND use an established screening tool
such as SAFE-T
Call for help!
Be sure to document your rationale
Stick around for SKA2 blood test?
The End!
Next Week's
Topic:
Assessing
Bipolar
Disorder in
the Primary
Care Setting