Provider Card Final

VA / DoD SUICIDE PREVENTION PROVIDER CARE CARD IDENTIFICATION and ASSESSMENT DETECTION and SUICIDALITY

Suicidal Intent and Lethality History of Overt Suicidal / Self-destructive Behavior  Are suicidal thoughts and/or feelings present?  Have suicidal behaviors occurred in the past? - What are they? - Explore the circumstances of past suicidal attempts. - Are they active/volitional or passive/non-volitional? Ability to describe the past event may provide the best - When did they begin? window into the current state of mind. Absence of - How frequent are they? suicidality does not eliminate the risk of current or - How persistent are they? future attempts. - Are they obsessive?  Statistical relationships of suicide attempts to - Can the patient control them? suicide completion are: - What motivates the patient to die or continue living? - Attempters are at increased risk for suicide over the Dynamic Meanings and Motivation for Suicide general population by 7-10%. - 18-38% of completed suicides have made a prior  What form does the patient’s wish for suicide take? attempt. - Is there a wish to die, to hurt someone else, or to - 1% of past attempters kill themselves each year. escape, to punish self?  Has the patient engaged in self-mutilating  What does suicide mean to the patient? behaviors? - Is there a wish for rebirth or reunion? - Wrist-cutting or other self-mutilation suggests consid- - Is there identification with a significant other? eration of the diagnosis PTSD or dissociative disord- - What is the person’s view of death and his/her re- ers. When a history of trauma is present, assess the lationship to it? presence of a mood disorder. - Does death have a positive meaning for the patient? - Although self-mutilation is frequently an act of self- soothing rather than an attempt, patients who self-  Has the patient lost an essential relationship? mutilate do sometimes commit suicide.  Has the patient lost his/her main reason for living? Physiologic, Cognitive and Affective Status (These losses can be threatened.)  Does the patient’s mental state increase the Presence of a Suicidal Plan potential for suicide? (presence of energy and hopelessness)  How far has the suicidal planning process - Suicide requires the ability to organize & the energy to proceeded? implement a plan.  Specific method, place, time? - Suicide potential may be heightened when there is - Available means? greater energy (as in early recovery from depression) - Planned sequence of events? or lowered inhibitions (as during intoxication or rage). - Intended goal? (death, self-injury, other outcome) - Hopelessness is a key psychological factor in suicidal  Feasibility of plan? intent and behavior. - Access to weapons? Consider the possibility of misin- - Suicide is often accompanied by pervasive negative formation. expectations.  Lethality of planned actions?  Are depression and/or despair present? - Objectively assess danger to life.  Does the patient’s physiologic state increase the - Objectively question patient’s conception of lethality. potent-ial for suicide? (acute intoxication, withdrawal, or - Avoid terms such as gestures or manipulation chronic abuse) because they imply a motive that may be absent or  Is the patient vulnerable to painful affects such as irrelevant to lethality. alone-ness, self-contempt, murderous rage, shame or - Bizarre methods have less predictable results and panic? may therefore carry greater risk. - Pay attention to violent, irreversible methods such as The Patient’s Coping Potential shooting or jumping.  Are there recent stressors in the patient’s life?  Likelihood of rescue? - Is the patient facing a real or imagined loss, disappoint- - Patients who contemplate a plan likely to end in dis- ment, humiliation or failure? covery may be more ambivalent and/or attached to - Has there been a disruption in the patient’s support people than others who plan their suicidal behavior to system, including treatment? occur in an isolated setting.  What are the patient’s capacities for self-  What preparations has the patient made? regulation? (obtaining pills, suicide note, making financial - Does the patient have a history of impulsive behavior? arrangements, giving away possessions) - Does the patient need, and use external sustaining  Has the patient rehearsed for suicide? (rigging a resources to regulate self-esteem? Developed by the Suicide Risk Advisory Committee Members of the Risk Management Foundation, noose, putting a gun to his/her head, driving near a Harvard Medical Institutions,Is the 1996. patient www.rmf.harvard.edu. able to participate Reprinted with in permission.treatment? VA/DoD Substance Use Disorder bridge or other serious threat). - Is there willingnessClinical Practice to comply Guideline with a treatment plan? - Is there capacity forApril making 2002 an alliance?

VA / DoD SUICIDE PREVENTION PROVIDER CARE CARD IDENTIFICATION and ASSESSMENT MENTAL HEALTH DISORDERS CORRELATED with SUICIDAL BEHAVIOR Mood Disorders (15% lifetime risk of suicide) Schizophrenia (10% lifetime risk of suicide)  The absence of psychosis does not imply safety.  Relatively uncommon during psychotic episodes.  A misleading reduction of anxious or depressed  The relationship between command hallucinations affect can occur in some patients who have resolved and actual suicide is not clearly causal. the ambivalence by deciding to commit suicide. A  Suicidal ideation occurs in 60-80 % of patients. patient who has made the decision to die may appear  Suicidal attempts occur in 30-55% of patients. at peace and not show signs of an inner struggle.  Suicide potential is increased by good premorbid Concern is warranted; especially when the patient functioning, early phase of illness, hopelessness or appears emotionally removed, shows constricted depression, and/or recognition of deterioration (during a affect, or is known to have given away belongings. post-psychotic depressed phase).  The likelihood of suicide within one year is Panic Disorders (7-15% lifetime risk of suicide) increased when the patient exhibits panic attacks,  Suicide rate may be similar to that of mood psychic anxiety, anhedonia, and/or alcohol abuse. disorders.  The likelihood of suicide during the ensuing 1-5  Greater likelihood is correlated with more severe years is increased when the patient exhibits increased illness or comorbidity. hopelessness, suicidal ideation, and/or history of  Suicide does not necessarily occur during a panic suicide attempts. attack. Borderline Personality Disorder (7% lifetime risk of  Demoralization or significant loss increases the suicide) likelihood of suicide.  Much higher risk associated with comorbidity,  Agitation may increase the likelihood of especially with mood disorder and substance abuse. translating impulses into action. Psychopathology associated with increased risk  Alcoholism (3% lifetime risk of suicide) includes: impulsivity, hopelessness and despair,  Abusers of alcohol/drugs comprise 15-25% of antisocial features (with dishonesty), interpersonal suicides. aloofness (“malignant narcissism”), self-mutilating Alcohol is associated with nearly 50% of all tendencies, and psychosis with bizarre suicide  suicides. attempts.  Increased suicide potential in an alcoholic patient  Psychopathology associated with diminished risk correlates with active substance abuse, adolescence, includes: infantile personality (with hysterical features) second or third decades of illness, and/or recent or and masochistic personality. anticipated interpersonal loss.  Substance abuse can represent self-treatment to blunt the anxiety or mood disturbance associated with a masked, comorbid psychiatric disorder. SUICIDE RISK FACTORS The following risk factors provide explicit criteria for identifying the presence of factors correlated with a greater likelihood of suicide risk. With any individual patient, they assume greater or lesser importance. Under the Age of 30: (Adolescents & Young Adults) Over the Age of 30:  Family history of suicide  Family history of suicide  Males > females  Males > females  History of previous attempts  History of previous attempts  Psychiatric diagnosis - mood disorders & substance  Native American abuse  Psychiatric diagnosis - mood disorders, schizophrenia  White > black alcoholism  Mini-epidemic in community  Single, especially separated, widowed or divorced  History of delinquent or semi-delinquent behavior  Lack of social supports even without depression in current mental state  Concurrent medical illness (es)  Presence of firearms (when other factors are  Unemployment present)  Decline in socioeconomic status  History of adverse childhood exposures  Psychological turmoil  History of adverse childhood exposures OTHER CONDITIONS WHICH CAN INCREASE SUICIDE RISK  Physical illness, particularly associated with  Family history of psychiatric illness & particularly of chronic pain suicide  Delirium associated with organic illness  Other personality disorders/states  Psychopathology in family & social milieu,  The presence of firearms in the home (particularly for including life stress & crisis adolescents) Developed by the Suicide Risk Advisory Committee Members of the Risk Management Foundation, Harvard Medical Institutions, 1996. www.rmf.harvard.edu. Reprinted with permission.