Objective Two
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Role of Health Care Provider
All health care providers should:
• Be cognizant of suicide risk factors
• Be able to identify individuals who demonstrate
a higher risk for suicide
• Be able to empathetically and appropriately
screen for suicide intent and plans
• know where to refer a high risk individual for a
more detailed assessment and intervention
• Remember: Providers MUST inquire about
suicide whenever appropriate – asking does not
increase suicide risk, asking decreases suicide
risk
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Guiding Principles for Suicide Risk
Assessment
Suicide Risk Assessment:
• Is therapeutic and Occurs in the Context of a Therapeutic Relationship
• Is Unique for Each Person
• Is Complex and Challenging
• Is an Ongoing Process
• Errs on the Side of Caution
• Is Collaborative and Relies on Effective Communication
• Relies on Clinical Judgment
• Takes All Threats, Warning Signs, and Risk Factors Seriously
• Asks the Tough Questions
• Tries to Uncover the Underlying Message
• Is Done in a Cultural Context
• Is Documented
So, What to do? - identification
Enquire about suicide risk if the person:
• Has signs and symptoms of a mental disorder or a
history of suicide attempts or self-harm
• Is extremely agitated but cognitively intact
• Has made a self injury attempt
• Is an “unusual” health care visitor (for example, a
teenager presenting to the ER without a physical injury;
a middle aged man who has rarely used health services
coming to see a health provider with vague physical
complaints; a usually competent woman who presents
complaining of “being totally burnt out”
• Friends or family members raise concerns about the
persons’ mental state
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So, what to do? – general
questions
Ask simple, empathetic questions about the
person’s general emotional state:
• It seems as if things have been difficult for you
lately. Tell me about what has been happening?
• Is seems as if you are having some emotional
difficulties. What is going on?
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Positive Response to General
Questions - now what?
• If the person provides information about a
difficult emotional state or significant mental
health problem the next set of questions
becomes more focused.
• Keep the tone and flow of the history taking
empathetic, non-judgmental and supportive.
• Do not dramatize or over-emphasize.
• Do not agree to keep information about selfharm or suicide confidential.
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So, what to do? – focused
questions
Ask simple focused questions designed to elicit
thoughts of death or dying.
• Sometimes when people feel the way you do,
they think there is no way out for them. What
about you?
• When people are feeling badly, as you are,
sometimes they think about death or dying.
What about you?
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Positive Response to Focused
Questions – now what?
• If the person provides information that leads
you to believe that they have suicidal intent, the
next set of questions become targeted to that
issue.
• Remember to keep the tone and flow of the
history taking empathetic, non-judgmental and
supportive.
• Remember that information about self-harm or
suicide intent/plans can not be kept confidential
from other health care providers.
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So, what to do? – targeted
questions
Ask simple targeted questions designed to elicit
presence of suicidal intent.
• Often when people are feeling that way, they
think they would be better off dead. What
about you?
• Often when people are feeling that way, they
think about taking their own life. What about
you?
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Patient Who Acknowledges Thoughts of
Suicide
• Determine the nature of the thoughts with questions such as:
• "When did you start having these thoughts?"
• "What was going on in your life at time of these thoughts?"
• "Are they continuous?"
• "How often do you have the thoughts?"
• "How intense are these thoughts?"
• "Do you have difficulty thinking of anything else?"
• "How likely are you to act on these thoughts?"
For individuals with psychosis, ask specifically about hallucinations and
delusions:
• "Tell me about the voices. What do they say?"
• "Have the voices ever told you to harm yourself or to end your life?”
• If yes, ask "is it difficult to ignore them?"
Positive Response to Targeted
Questions – now what?
• If the person provides information that leads
you to believe that they have a suicide plan, the
next set of questions become directed to that
issue.
• Remember to keep the tone and flow of the
history taking empathetic, non-judgmental and
supportive.
• Remember that self-harm or suicide intent/plans
can not be kept confidential from other health
providers
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So, what to do? – directed question
Ask a simple directed question designed to elicit
presence of a suicide plan.
Often when people think that way they think of a plan
of what they would do to die. What is your plan?
You will notice that this question assumes the person
has a plan. It is a leading question and is designed to
be a leading question. Phrased in this manner the
question gives permission to answer if a plan is
contemplated. The person without a plan will state
that they do not have one. Obtain as many details
about the plan as possible.
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Patient Has a Plan – Now What?
• This is a point for immediate referral to a specialist who
can provide a more in depth analysis of suicide risk.
• The person should be told that you are concerned about
their safety and well-being and that you will ask a
colleague who is more knowledgeable about how to help
them deal with their problem to see them now. If they
refuse then involuntary certification to a designated
facility will be necessary.
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Patient Has a Plan – Now What?
• Sometimes the person will deny having a plan
but they have either voiced a strong suicide
intent or you are suspicious that they have
intent or even a plan but are not sharing the
information with you.
• This is particularly important if the person
seems to be or expresses that they are
hopeless. In this case a referral for further
specialist assessment is also indicated.
Additional Assistance has been Requested
– now what?
In an Emergency Room or Clinic Situation
• Remove items that can be used for self-injury and place
the patient in an appropriate and safe location.
• Share your concerns and communicate the risk level
with the rest of the team.
• If friends or family are present, obtain collateral
information.
• Document your findings. If appropriate, it is reasonable
to complete the medical/psychiatric history and details
of the current situation ensuring that you address the
points related to suicide risk. You can use the NSTASR© to assist you with your suicide risk assessment.
• Ensure that the person does not leave until you discuss
your interview with the consultant.
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Additional Assistance has been Requested – now
what ? (Part two)
• In a community office
• Remove items that can be used for self-injury and place
the patient in an appropriate and safe location.
• Share your concerns and communicate the risk level with
the rest of the team.
• If friends or family are present, obtain collateral
information.
• Document your findings. If appropriate, it is reasonable
to complete the medical/psychiatric history and details of
the current situation ensuring that you address the
points related to suicide risk. You can use the NSTASR© to assist you with your suicide risk assessment.
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In a community office (Continue)
• Contact the nearest acute care service and speak with a
person responsible for intake and assessment. Organize
safe and responsible transportation to the facility
(ambulance or other appropriate method).
• Ensure that the person does not leave until the
transportation has been provided.
• Discuss your interview with the consultant who assesses
your patient and be satisfied with the person’s disposition.
Using the NS-TASR©
• It is a tool that can be used by any health provider to
assist them in the identification of an individual with
higher risk for suicide
• It is used after the initial interview to ensure that the
most substantive risk factors have been assessed
• It should be used to help evaluate potential suicide risk
in those person’s who the health provider has identified
as having suicide risk
• The tool DOES NOT predict suicide. It is a tool to assist
the clinician in evaluating suicide risk. There is no tool
that can predict suicide.
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Documentation
• It is critical to document in a timely and accurate manner
when assessing a patient’s level of suicide risk.
• Documentation helps to:
• Communicate patient health information (i.e., suicide risk
information) to other healthcare providers
• Facilitate evaluation of the patient’s progress towards
desired outcomes
• Demonstrate clinicians accountability for care provided.
Advice for family or friends
• Discuss the issue of suicide and provide links to
reliable information about suicide and suicide
risk.
• Facilitate their understanding of the importance
of pursuing effective treatments for mental
disorders.
• Advise on the removal of lethal means from the
home: firearms, medications, etc.
• Inform about the appropriate use of 911 for
emergency situations.
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Clinical Pearls
• Rapid discontinuation of lithium treatment is
associated with a significantly increased risk for
suicide
• Auditory hallucinations (called command
hallucinations) can tell a person to harm or kill
themselves and thus increase risk for suicide. If
a patient acknowledges auditory hallucinations –
get exact details of what the voices are saying
• The true medical lethality of an event is not a
good indicator of the actual lethality of the
intent to die.
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Antidepressants and Suicide
• The use of SSRI medications DOES NOT increase suicide
rates
• The use of antidepressants (including SSRI’s) is
associated with a substantial DECREASE in suicide rates
• Some individuals treated with antidepressants may
experience suicide ideation, suicide intent, self-harm or
suicide attempts
• All patients being treated with an antidepressant should
be appropriately monitored for treatment associated
suicide phenomenon
• Patients with suicidal ideation can be safely and
effectively treated with antidepressants, properly
monitored
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Legal Obligation
• If a patient is judged to be at high risk of suicide,
but refuses further assessment or admission to an
appropriate facility, the health care provider has a
legal obligation to conduct or ensure the conduct of
an appropriate psychiatric assessment.
• This may require placing the patient under
“involuntary” status and providing the appropriate
and safe delivery of the patient to a designated
facility for the assessment to be conducted.
• Further information about “involuntary status”
designation can be found here:
http://www.gov.ns.ca/health/mhs/ipta.asp
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I have completed this skills upgrade:
now what?
• Suicide is a complex issue and not every person
who is at high risk of dying by suicide will be
helped with this or any other single approach.
• Training of health providers in assessing suicide
risk has been shown to help bring down suicide
rates and it has additional positive health benefits
in that some people may be able to access
necessary mental health care as a result of your
intervention.
• Thanks for taking the time to upgrade yours.
• Please go on to the post upgrade quiz to complete
the process and receive your certificate.
Dr. Stan Kutcher
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Some Additional Material
• Dr. David Knesper’s approach for mental health
professionals:
www.med.umich.edu/depression/suicideassess
ment
• The Nova Scotia report on Suicide in NS – 2009:
http://www.gov.ns.ca/hpp/publications/Suicide_
Report.pdf
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References
• S. Chehil and S. Kutcher . Suicide Risk
Management: A Manual for Health Professionals.
Blackwell, Oxford. 2012.
• S. Kutcher and M. Szumalis. Suicide Risk
Management. BMJ, Point of Care Series, 2010
• Kutcher, S., Gardner, D. SSRI Use and Youth
Suicide: Making Sense of a Confusing Story. Current
Opinion in Psychiatry. Jan;21(1):65-9, 2008
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