QME Suicide Risk Assessment and Managementby William W. Deardorff, Ph.D, ABPP.
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COURSE OUTLINE
Injured Workers and Suicide Risk Introduction to Suicide Risk and Management Learning Objectives Suicide in the United States Materials for the Course Framework for Suicide Risk Assessment and Management Agreeing on Terms and Definitions Potentiating Risk Factors Warning Signs Protective Factors Tools of Suicide Risk Assessment The Clinical Interview Therapeutic Alliance Countertransference A Proposed Model for Assessment Overview of Risk Factor Areas Predisposition to Suicide Stressors or Precipitants Symptomatic Presentation Presence of Hopelessness The Nature of Suicide Thinking Previous Suicidal Behavior Impulsivity and Self-Control Protective Factors Actuarial Risk Assessment Instruments What do I do with all of this Information? Suicide Risk Level and Appropriate Responses A Comment on No-Suicide Contracts Alternatives to the No-Suicide Contract Commitment to Treatment Statement Crisis and Response Plan Suicide Management Thorough Assessment of Suicide Risk Establishing an Appropriate Management Plan Involve Family Members and/or Significant Others Consult with other Professionals Implement the Plan Assuming Professional Responsibility Guides to Assessment and Management of Suicidal Behavior Assessment of Suicidal Risk A Decision-making Framework Outpatient Management Strategies Documentation Strategies Coordination with Inpatient Care Clinic Support and Peer Consultation Ensuring Continuity of Care Links with the Community and Self-Help Focus A Special Population: Geriatric Patients Increased risk in Geriatric Patients Masked Depression in the Elderly Accurate Identification of Depression in the Elderly Treatment Suicide in the Patient without Depression A Special Population: The Injured Worker and Suicide Learning from our Mistakes Lack of Communication between Therapists Permitting the Patient or Relatives to Control Therapy Therapist Avoidance of Issues Related to Sexuality Ineffective/Coercive Actions Due to Therapist’s Anxiety Not Recognizing the Meaning of Patient’s Communications Untreated or Undertreated Symptoms Documentation Summary and Conclusions Resources References
Injured Workers and Increased Risk for Suicide
People suffering serious workplace injuries often face ongoing physical and mental health issues, but new research suggests their situations outside of work may be even more dire. An injury severe enough to keep an employee home for at least a week almost tripled the combined risk of suicide and drug overdose death among women, and raised that risk 50% among men, according to a new study.
Serious workplace injuries are associated with increased risks of both suicide and death related to opioid overdose, according to a recent published in the American Journal of Industrial Medicine (Applebaum et al., 2019). The findings suggest that serious on-the-job injuries may be one factor that explains the uptick in suicides and overdose deaths nationally. “This study suggests that serious work-related injuries may contribute to the alarming rise in deaths from both opioid overdoses and suicide,” said lead author Kate M. Applebaum, ScD, MSPH, an associate professor of environmental and occupational health at the George Washington University Milken Institute School of Public Health (Milken Institute SPH). “We must continue to advance research to better understand the relationships between workplace injury, opioids and mortality. In addition, better treatment of the pain, substance use disorders and depression that often go along with workplace injuries may reduce this mortality risk.”
Applebaum and her colleagues studied more than 100,000 workers in New Mexico from 1994 through 2000, including 36,034 who had suffered an occupational injury serious enough to require a week off from work. The researchers looked at a combination of data on worker compensation injuries, Social Security earnings and mortality data, and cause of death from the National Center for Health Statistics. Workers were followed post-injury for up to 20 years in order to study long-term mortality trends. The study found that these serious workplace injuries nearly tripled the risk of suicide and overdose death for women and raised the risk by about 50 percent for men. They found that men with a lost-time injury were 72% more likely to die from suicide, and 29% more likely to die from drug-related causes. Women were even worse off; those with lost-time injuries were 92% more likely to die from suicide, and 193% more likely to die from drug-related causes. The report did not offer an explanation as to why women suffered such worse outcomes, considering that overall, more American men die from opioid overdoses than women. And while more women attempt suicide, men are more likely to die from it, according to the American Foundation for Suicide Prevention — although that gap is closing between boys and girls. Limitations of the study included only looking at workers in one state. The data provided also didn’t identify mortality risk factors that the workers had before their injuries, such as underlying diseases, BMI and whether they used drugs, cigarettes, or alcohol.
Drug overdoses and suicides have been rising in the United States for about a decade. Many experts blame the opioid crisis for these so-called “deaths of despair,” but this is the first study to link these deaths to workers who had serious job injuries. Previous studies have linked serious workplace injuries to both depression, which can trigger a suicide attempt, and the use of opioid painkillers, Applebaum said.
Suicide and Workers’ Compensation
Overall, studies have shown that suicides related to workplace issues are on the rise, and the cause is often increased workplace stress and excessive workloads. Under what circumstances should the family of a worker who takes his or her own life be awarded workers’ compensation benefits? Below, various cases are reviewed from Pennsylvania, Michigan, and California.
Pennsylvania A worker injured his lower back at work. The injury was deemed compensable, and the employer paid him some workers’ compensation benefits. The employer then offered the worker a light duty job. He attempted to do the work but was unable to due to continued back pain. He became depressed and developed irrational thoughts – he obsessed about the idea of being fired, losing the family home, and not being able to send his son to private school. He also worried he was being followed. While he was treated for general anxiety before the work injury, his mental status considerably worsened after the injury. Approximately nine months after the work injury, the worker committed suicide. His surviving spouse then filed a claim for survivor’s death benefits. She prevailed at trial, and the appellate board affirmed the trial judge’s decision.
While on appeal at the Pennsylvania Commonwealth Court, the employer argued that the award of benefits should be reversed because injuries arising from intentional and self-inflicted acts are not compensable, and suicide is clearly such an act. The court rejected the employer’s argument, and instead relied on a legal test that the majority of other jurisdictions have adopted: the chain-of-causation. This test deems suicide to be a compensable injury when all of the following criteria are present. There was initially a work injury; The “injury directly caused the employee to become dominated by a disturbance of the mind of such severity as to override normal rational judgement;" and The disturbance resulted in the employee’s suicide. The court ultimately determined that all of the elements of the chain-of-causation test were present, and as a result, it affirmed the award of survivor’s benefits to the decedent's spouse.
Michigan While the current law in Michigan is very similar to Pennsylvania’s chain-of-causation test, this was not always the case. In Hammons v Highland Park Police Dep’t, 421 Mich 1 (1984), the legal issue was whether a widow was entitled to survivor’s benefits after her police officer husband committed suicide because he was denied a promotion. The law at that time, called the delirium of frenzy test, awarded survivor’s benefits when a worker who, as a direct result of a physical injury at work, takes his or her own life through an “uncontrollable impulse or in a delirium of frenzy” and without the knowledge of the physical consequences. In practice, courts would look at whether a worker deliberately planned their suicide and understood that it would result in death. If so, then benefits would not be awarded. The Hammons court rejected the delirium of frenzy test and adopted a new one – the causal connection test. The court described this new test very plainly: “If the work results in a compensable mental injury and the mental injury results in suicide, the suicide is compensable.” We can think of Michigan’s causal connection test as having two parts: (1) Work must result in a compensable mental injury, and (2) The mental injury results in suicide.
In order to satisfy the first prong of the test, a claimant must establish that the decedent developed a work-related mental disability as that term is defined in MCL 418.301(2) and MCL 418.401(2)(b). These statutory provisions, which are nearly identical, provide that a mental disability is compensable when: (1) the plaintiff’s mental disability resulted from actual events of employment, (2) the worker’s perception of the events is not unfounded and is grounded in reality, and (3) the work contributed to the mental disability in a significant manner. See Robertson v DaimlerChrysler Corp, 465 Mich 732 (2002). This requires a magistrate to compare the employment and non-employment factors contributing to the decedent’s general mental health. See Gardner v Van Buren Pub Sch, 445 Mich 23 (1994). If the claimant satisfies the causal connection test's first prong, the claimant must then prove the easier second prong. This usually requires minimal effort because there is usually an obvious connection between one’s mental disability and subsequent suicide. See Wegener v East Lansing Pub Sch, 454 Mich 879 (1997) and Aubrecht v Co Op Servs Credit Union, 1998 ACO #495.
California Although suicide can be formulated as a willful act, there are times in which someone may kill themselves but have not formulated the intent to do so. A classic example of a death without suicidal intent is an individual who takes too many of a particular medication. The individual may not have realized that the excessive amount taken was lethal. There are times an individual may be taking multiple medications at the same time that are contraindicated. The combination of these drugs, unknown to the Injured Worker, is lethal. Finally, there are Injured Workers who combine prescription medications with street drugs or alcohol. The mix can have a lethal result. Again, the individual may or may not have intended the combination to be lethal in nature.
A case relating to this was the City of Foster City, The Cities Group, Petitioners v. Workers’ Compensation Appeals Board 78 C.C..C. 1330 (writ denied.) In that case, “[a]n autopsy revealed Decedent had a lethal concentration of hydrocodone in his blood. Low doses of Valium were also found in Decedent’s blood. The coroner concluded that Decedent died as a result of acute hydrocodone and hydromorphone intoxication. The coroner did not, however, rule the death of suicide. It was noted in the WCJ’s opinion, that “[t]here is no evidence that Mr. McLaughlin intended to cause his death, or knowingly acted with the knowledge that there would be a great likelihood of overdosing, as asserted by the defendant. Defendant has not met its burden of proving a statutory exception under either Labor Code § 3600(a)(4) or any other statute to a finding of compensable death.”
Related to the issue of suicide under the Labor Code, there is a section concerning intentional acts. Labor Code Section 3600(a)(5) provides for an exception to the entitlement to compensation benefits where the injury is intentionally self-inflicted. Suicide, by its definition, is a self-inflicted injury. Therefore, in general, death as a result of suicide will not be compensable. There are workers’ compensation cases, however, which find an exception to the general rule.
Labor Code section 3600, subdivision (a)(6) prohibits recovery of workers’ compensation benefits if the employee “willfully and deliberately” caused his own death. Because the decedent’s mental state determines eligibility, it is subjected to intense legal and medical scrutiny. An employee need not be criminally insane or in a delusional frenzy. (Donovan v. Workers’ Comp. Appeals Bd. (1982) 138 Cal.App.3d 323, 327–328 [187 Cal. Rptr. 869, 47 Cal. Comp. Cases 1411] (Donovan). The suicidal act can be one of conscious volition; the person can indeed understand the nature and consequences of what he is doing. (Burnight v. Industrial Acc. Com. (1960) 181 Cal.App.2d 816, 826 [5 Cal. Rptr. 786, 25 Cal. Comp. Cases 121] (Burnight).) ” ‘Where the suicide of an employee is directly caused by his injuries and their consequences, his death is not intentionally self-inflicted or willful so as to bar compensation, where he kills himself under compulsion of an irresistible or uncontrollable impulse, or while in a delirium or frenzy or where the injuries suffered by the deceased result in his becoming devoid of normal judgment and dominated by a disturbance of mind.’ [Citation.]” (Id. at p. 822.) See Toshi v. Workers’ Compensation Appeals Bd., 72 Cal. Comp. Cases 420, 2007 Cal. Wrk. Comp. LEXIS 111 (Cal. App. 3d Dist. April 03, 2007)(Not published) (Note: case is not a citeable case. The caselaw discussed within it, however, is informative as to the exception to the bar from compensation for self-inflicted acts.)
In sum, suicide may be compensable if there was some disturbance that compromised the Individual’s control during the commission of the act. If there is a psychiatric claim, and the psychiatric claim is compensable, there can be a claim for industrial suicidal. Caselaw suggests that there must be an underlying compensable psychiatric injury in order to claim a compensable suicide. In Rockefeller v. Workers’ Comp. Appeals Bd., 83 Cal. Comp. Cases 1588, 2018 Cal. Wrk. Comp. LEXIS 79 (Cal. App. 3d Dist. August 16, 2018) (writ denied), it was noted that since there was no compensable psychiatric injury, there could be no finding of an industrially-related suicide. If there is a suicide that is considered work-related, then death benefits are available to the Dependents. There are, however, time frames for filing death claims.
INTRODUCTION TO SUICIDE RISK AND MANAGEMENT
“There are two types of mental health therapists: those who have had a patient commit suicide and those who will”
Most therapists receive very little formal training on the assessment and management of the suicidal patient. It has been estimated that between 40% and 70% of graduate programs provide no curriculum-based education in this area (Oordt et al., 2009; Dastagir, 2020). This means that most practitioners must learn about this important aspect of practice from during a supervised experience, continuing education, or self-taught when the need arises. This is certainly not an ideal situation for equipping professionals with managing one of the most important issues in practice. The lack of attention to formal education in this area is likely due to its low base rate. But even with the low base rate, suicide does not occur on continuum; if completed is it “all or nothing”, underscoring the importance of having expertise in this area. In addition, due to managed care and limited resources, inpatient care for suicidal patients has become increasingly limited, meaning providers have to provide quality management of the suicidal patient on an outpatient basis. Even so, there is increasing evidence that outpatient management of the suicidal patient can be appropriate, safe, and often preferable to inpatient care. All of these issues will be discussed in this course.
Seeing a patient with suicidal ideation or behavior is one of the most challenging and emotionally-charged areas in mental health practice. It is also highly likely to occur on one or more occasions in a professional’s career. In fact, the possibility of confronting a situation involving a suicide or suicide attempt is ever-present in practice. Consider the following statistics presented in Table 1 (The most recent studies of this type. See Schwartz & Rogers, 2004; Tsao & Layde, 2007 and references for a review):
Effect on the therapist. Patient suicides are among the most traumatic events in a clinician’s professional life. Studies show that suicide is the number one source of stress for therapists (the emotional impact of a patient’s suicide is comparable to the death of a family member).
Suicide in the United States
The following Table presents an overview of the most recent US statistics related to suicide. This is general data and more detailed information can be found on the NIMH and CDC web sites. As will be seen, this information is important since it provides data that enters into the suicide risk assessment process. Those in these static higher risk groups might be assessed more carefully and more frequently as part of mental health treatment. For instance, according to this demographic data, an 85-year-old white male already has increased risk regardless of any other factors (that will be discussed in this course such as mental illness, substance use, impulse control, etc.).
From the government websites, data can be found for any other group that may be at a predisposed risk (e.g. military, adolescents, etc.). All of these factors represent risk factors that must be assessed along with those presented in the individual situation. If you specialize in working with any group that already has an elevated suicide risk (statistically) suicide risk assessment and closer monitoring takes on increased importance.
Materials for the course
This course is based on all the content contained herein as well as other outside resources. These resources are in the public domain and are primarily official guides that include reviews of the literature. Although all the information is summarized in the following, the course also includes review of these publications.
Framework for Suicide Risk Assessment and Monitoring
The following framework is adapted from materials in the Table above and other resources (See resources and references). As discussed in the HCO Guide (p. 65):
“Suicide risk assessment needs to be thorough, person-centered, and simple. It needs to incorporate multiple approaches to ascertain a person’s level of distress and risk of suicide.”
The process of suicide risk assessment is just as important as the assessment tool(s) chosen for use. The clinician, depending on a number of factors, will decide which approach or combination of approaches works best in his or her particular setting and patient population. The HCO Guide, based on the extant research in the area and interviews with experts, suggests that clinicians should:
Beware of warning signs, potentiating risk factors, and protective factors Use good clinical judgment as well as other information about the patient Document findings Appropriately monitor the patient Agreeing on Terms and Definitions When discussing suicide risk assessment and management, it is important to be able to agree on terms and definitions to insure accurate communication (O’Connor et al., 2013; Rudd, 2008; Rudd et al., 2006; Wasserman et al., 2021). In some cases, patients with different characteristics will need to be assessed and managed very differently (e.g. history of suicide attempts versus instrumental suicide-related behavior versus self-harm). Current terminology can be found in Table 3.
When completing a suicide risk assessment, it is important to distinguish between some other key concepts beyond defining terms. For instance, some risk factors are associated with suicide (potentiating risk factors and/or chronic risk factors) and some are known to actually increase the risk of suicide (acute or warning signs). Potentiating or chronic risk factors tend to be static and do not change much over time. These risk factors do not necessarily indicate that a person is at increased risk for an imminent attempt. On the other hand, acute or warning signs are dynamic and are those factors that suggest suicidal behavior may be set in motion in the very near future. Warning signs may suggest the heightened risk of suicide in the short term even in the absence of potentiating/chronic risk factors. Alternatively, potentiating/chronic risk factors may predispose a person to a chronic heightened risk of suicide in which warning signs may not be present (but when they emerge, may represent an emergent situation). The interplay between potentiating risk factors and warning signs will be discussed further after the presentation of the specific factors (See Table 4).
In addition, it is important to distinguish between chronic suicidality and acute suicidality since these patients must be managed differently. Chronic suicidality presents differently from acute suicidality, and the treatment approach is different. For instance, hospitalization of the chronically suicidal person (absent significant warning signs) has little value in preventing suicide and may have a negative effect (repeated admission, destruction of therapeutic alliance). The chronically suicidal patient may present symptoms over the long term (e.g. months or years) but still must be assessed and monitored for emergence of acute suicidality (warning signs). Treatment of the chronically suicidal patient often includes addressing the underlying reasons for the symptoms (e.g. personality disorder, as a means to express distress). In these cases, the clinician must often tolerate the suicidality over extended periods and provide treatment in the least restrictive setting (e.g. outpatient) even when there is a slightly elevated risk.
The following figure demonstrates the interplay between Protective Factors and Risk Factors across various domains including individual, relationships, community and societal (Office of the Surgeon General, 2012).
TOOLS OF SUICIDE RISK ASSESSMENT
The assessment of suicide risk is most often based upon the identification and appraisal of potentiating/chronic risk factors, acute/warnings signs AND protective factors that are present. The assessment should always include a clinical interview and collection of other important information as appropriate (past treatment records, information from family, etc.). The clinical interview can be augmented by risk assessment instruments. As this material is presented, the reader may walk away with the feeling that an appropriate suicide risk assessment is an onerous, lengthy, complex task and might take the better part of a full day to complete. Actually, much of the information that will be reviewed should be collected as part of any initial clinical interview and is not unique to suicide risk assessment. This presentation discusses how to think about, and organize, information that is routinely collected, along with adding some key questions unique to this area. Subsequently, some suggestions for documentation of the risk factors assessment will be discussed. The Clinical Interview
Therapeutic alliance. Most clinicians in practice probably use the clinical interview (and follow up interviews or treatment sessions) as their primary source of data in completing a suicide risk assessment. One of the key elements of an effective clinical interview (assessing suicide risk factors or anything else), is rapid establishment of the therapeutic relationship. In some settings, the suicide risk assessment may be vulnerable to becoming automated and focus solely on triage of services or gathering the necessary information as quickly as possible (checking off the boxes). Therefore, the primary principle for maintaining a person-centered risk assessment is the establishment of a therapeutic relationship (American Psychiatric Association, 2003). This relationship is based on utilizing the clinical skills with which the reader should be familiar (e.g. active listening, trust, respect, genuineness, empathy, etc.). Patients can usually sense when a clinician is comfortable with the topic of suicide. At that point, the patient may feel safe enough to share important information about their suicidality, especially warning signs that suggest an attempt is imminent.
Countertransference and being comfortable with the topic. In addition to quickly establishing a therapeutic relationship, it is also important that the clinician be comfortable asking about suicide risk and protective factors, as well as having insight into any countertransference issues that might arise (e.g. feeling the patient “uses” suicide ideation or gestures in a manipulative fashion, etc.). Some of the countertransference issues that arise in the therapist might include (See Table 5):
Another countertransference issue actually relates to the goal of the suicide risk assessment (Rensko, 2017; Shea, 1998). As discussed by Shea (1998):
“It seems pertinent to raise a countertransference issue that many interviewers do not like to admit, but one which I think is present in most of us. Namely, if we uncover serious suicidal ideation, we are potentially creating a mess for ourselves.”
This type of countertransference leads the therapist to ignore comprehensive assessment of suicide risk factors in the first place and minimize their significance, if found, in the second place.
A Proposed Model for Assessment
Various researchers have developed models for assessment of suicide risk primarily based on the clinical interview (McCabe et al., 2017; Bryan and Rudd, 2006; Wasserman, 2021). An overview of these models, supplemented by other literature, will be presented here. There are a number of areas that have been empirically shown to be important to risk assessment and should be included as part of the clinical assessment.
When assessing suicide risk, it is important to distinguish between explicit and implicit intent. Explicit or subjective intent is the patient’s stated intent, or what the patient actually says during the interview (e.g. “Even though I have thought about killing myself, I would never do it”). Implicit or objective intent is estimated by the patient’s current and past behaviors, as well as his or her expressed understanding of the lethality of the method chosen (e.g. past attempts, means available, low impulse control, substance use, multiple stressors, lethal means available). When the clinician notices a discrepancy between implicit and explicit data, this should be pointed out to the patient and discussed. An example might be a person who says, “I would never really commit suicide……those weren’t real attempts in my past” while the data indicate likely history of lethal attempts, low impulse control, substance use, a gun in the house, lack of social support, etc. Bryan and Rudd (2006) suggest using a 1-to-10 rating scale as a useful method when doing a suicide risk assessment. This has several advantages including:
Examples of questioning using this method include the following (adapted from Bryan and Rudd, 2006, p. 190). Each of these types of questions is followed by, “on a scale of 1 to 10 with 1 being ______ and 10 being ______”. The therapist can decide on the anchors for each question and which direction equals a more or less severe direction.
How would you rate the severity of your hopelessness? How would you rate your intent to kill yourself right now? How would you rate the severity of the thoughts to kill yourself? How would you rate your hopefulness about the future? How would you rate your ability to seek help if you feel very suicidal?
Acute versus chronic risk. As discussed previously, it is important to keep in mind acute versus chronic risk factors. In general, chronic risk factors are similar to what was termed potentiating factors previously. These factors tend to be static. As will be reviewed in more detail later, each individual will have a chronic suicide baseline level which represents a compilation of the predisposing factors and ongoing issues. The baseline is the state in which the patient is going to be “as good as it gets.” Against that background, patients will show acute exacerbations preceded by the warning signs. These factors are considered “dynamic.”
Overview of Risk Factors Areas
The following is an overview of the risk areas presented in Table 6. It is beyond the scope of this course to present the detailed and extensive research relative to each area. For comprehensive review and practice guidelines the reader is referred elsewhere (Suicide Risk Assessment Guide Ontario Hospital Association, 2011; Wasserman, 2021; and the other resources listed in the previous Table and in the references).
Predisposition to Suicide Predispositions to suicide are stable (static) factors and should be assessed as part of any initial interview. These include previous history of psychiatric diagnoses, previous history of suicidal behavior, and history of abuse. Research suggests that a person is at a higher suicide risk within one year of release from inpatient psychiatric treatment. Even though warning signs may not be imminent, this represents a “chronic” risk factor. The other risk factors listed in Table 6 interact in somewhat complex ways and it is not a simple additive effect (e.g. more factors equals greater risk). For the clinician in practice, taking note of these potential factors, within the context of all other factors assessed, is important.
Stressors or Precipitants There are multiple issues that might be considered a stressor or precipitant to suicidal behavior. Some of these have been more consistently demonstrated in the literature and some will be unique to the individual patient. The use of the 1-to-10 rating method can give the clinician a rapid method for assessing just how stressful the issue is perceived by the patient. As listed in the Table, a stressor might include any significant loss such as financial (job, investments, lawsuit), interpersonal (marriage, other relationship, death of loved one), health problems (acute or chronic), or family instability (change in family structure for any reason such as divorce, loss of child custody, etc.).
Symptomatic Presentation Research has demonstrated a significant risk factor for suicide in the presence of a major mood disorder, especially during the depressive phase. As discussed by Bryan and Rudd (2006), and in this course earlier, because the base-rate of the behavior is so low (less than 1% of individuals who have an affective disorder commit suicide) it is extremely difficult for a practitioner to successfully identify which individuals with affective disorders are high risk. Research has identified some of the more potent predictors related to affective disorder symptoms. These include hopelessness, low self-esteem, and substance abuse/dependence. Relative to bipolar disorders, the risk is higher early in the course of the disorder. For schizophrenia, the lifetime risk of suicide is about 4% and peaks during young adulthood. Relative to personality disorders, the categories of borderline and antisocial appear to carry higher risk. Presence of Hopelessness A majority of suicidal patients report hopelessness (and gaining relief from it) as a primary motivator for the suicidal behavior. Therefore, the presence of hopelessness, along with its severity and duration should be carefully assessed. The Nature of Suicidal Thinking Although clinicians are often not comfortable discussing suicidal thinking with patients, it is extremely important to assess it in an open manner. Clinicians may have a tendency to avoid the topic thinking that “If I don’t bring it up, it won’t be an issue”. Suicidal thinking should be assessed for the following dimensions (See Table 7):
To enhance the therapeutic alliance and decrease resistance, it can be useful to discuss more remote suicidal episodes first and then move toward the present. The clinician might also need to take into account cultural issues and this line of questioning. Some cultures maybe more or less open to discussing suicide issues. As discussed by Bryan and Rudd, “hidden” suicide “ideators” exist in all groups and it is important to complete a full risk assessment to identify them. As the authors conclude, “We recommend that direct probing for suicidal intent be practiced as a general rule, not as a special circumstance” (p. 194).
Previous Suicidal Behavior It is important to not only assess previous suicide behavior but also the various dimensions for each attempt (See Table 8). In this process, it is important to distinguish between previous attempts (with and without injuries) and instrumental suicide-related behavior for each instance. This will give the clinician a very good idea of increased risk especially when “chronic risk” is identified. Research has demonstrated increased future risk is associated with number of previous actual attempts and the method of previous attempts. One must also pay close attention to those with a history of instrumental suicide-related behavior since these patients may underestimate the lethality of the method relative to future suicide attempts (or behavior). Impulsivity and Self-control This area should assess the patient’s perceived sense of self-control, objective identifiers of self-control, engagement in impulsive or self-destructive behaviors and methods for coping with stress (See Table 9 for examples).
The use of alcohol and other impulse control lowering substances has consistently been found to be associated with increased suicide risk. Also, the presence of impulsivity as a long-standing problem or personality trait may be a more significant risk factor than a formulated plan. This is due to the fact that suicide attempts are often in reaction to specific environmental stressors (often unpredictable). Protective Factors There are many factors that have been identified as associated with reduced risk for suicidal behavior and these have been termed protective factors. These are presented in Table 10. Although risk factors have a stronger relationship with suicidality than protective factors, the latter are important relative to treatment interventions. Protective factors are important to assess not only related to an overall suicide risk assessment, but also as a starting place for developing a suicide management treatment plan. Often, the treatment plan for a patient with suicidality will include enhancing protective factors while decreasing risk factors.
Actuarial Risk Assessment Instruments
Although most would agree that the core of the suicide risk assessment is the clinical interview, there are a number of suicide risk assessment questionnaires that have been empirically developed and measure various aspects of suicidality. They are most commonly used to augment the clinical interview.
It is beyond the scope of this course to review all of these measures, but some of the more popular ones in use can be found in the Suicide Risk Assessment Guide (Guide HCO; referenced previously). As can be seen, the Table provides the name of the scale, author, information about obtaining a copy of the test, copyright information and fees. In addition, a summary Table (click here for pdf) shows summary information about each scale such as number of items, cost, population use, etc. This information can help the clinician decide which type of actuarial assessment might be most appropriate given the particular clinical situation. These instruments should never be used as a stand-alone assessment for suicide risk. These instruments all have a slightly different focus, and the choice of a test will depend on the unique situation of its use (e.g. inpatient/outpatient, age group, treatment setting, etc.) As discussed by a number of authors (see resources and references), the use of these instruments is probably limited in clinical settings. There is no consensus on which tool is the most effective. In addition, none of the scales can predict actual suicide attempts. Several problems have to be kept in mind as can be seen in Table 11.
The most valuable aspect of most of the actuarial suicide risk assessment tools is the collection of additional, pertinent information that can assist in clinical decision making. In fact, most experts state that the summary scores obtained on these scales are NOT commonly used in practice to make firm decisions about a person’s risk for suicide. Rather, the actual content covered in the specific items of the tool themselves is more important than the summary scores or cut-off rules. Given these findings, adding an actuarial tool may enhance and specify the information gained from the clinical interview rather than providing specific decision-making conclusion based on summary scores or cut-offs. What do I do with all this Information?
We have now covered the type of information that should be gathered as part of a suicide risk assessment, conceptual issues related to suicide behavior, and actuarial tools that can enhance the process. The obvious question is, how does the clinician quantify this information and how does it guide decision making?
Many researchers (See Bryan and Rudd; Wasserman et al., 2021) distinguish baseline risk and acute risk. At baseline risk, the individual is not in a state of acute risk and is asymptomatic relative to imminent suicide risk. Even though potentiating (or static) risk factors may be present, the patient is at his or her best. The baseline level is unique to each patient. In some patients, the baseline may represent a state of chronic high risk. These patients show a history of multiple attempts along with more potentiating factors.
Acute risk (or exacerbation) occurs when other factors trigger a number of risk factors (warning signs) and the patient is at his or her worst. Acute risk can occur on top of any baseline, including chronic high risk. Hence, once can establish four categories of suicide risk:
There is an important reason for these distinctions. One cannot think of an individual as either “suicidal” or “not suicidal” when assessing and managing these patients. In contrast, (1) identifiable risk periods occur inconsistently and (2) chronic suicidality complicates any assessment.
Taking into account the above conceptualization, suicidality occurs on a continuum. Acute risk increases from non-existent, to mild, to moderate, to severe, and to extreme as intent emerges and becomes clearer in terms of both objective and subjective indicators. In addition, protective factors will either be minimal (long term) or fade if they had been present. The following is adapted from Bryan and Rudd (2006, p. 198) and others (See References and Resources). As illustrated in Table 12, the response by the clinician is directly correlated to the intensity of the risk factors. In the case of severe or extreme suicide risk, immediate evaluation for inpatient hospitalization is indicated (either voluntary or involuntary). As discussed by Bryan and Rudd, outpatient management of those at moderate and even severe risk can be accomplished taking into account the recommendations briefly summarized in the Table 12.
A COMMENT ON NO-SUICIDE CONTRACTS
Many clinicians were trained to use no-suicide or no-harm contracts as part of their education, and the practice is quite common in clinical settings. A typical no-suicide contract (NSC) contains the following (see Rudd, Mandrusiak & Joiner, 2006; Wasserman et al., 2021):
An explicit statement agreeing not to harm or kill oneself Specific details about the duration of the agreement A contingency plan if a crisis that would jeopardize the patient’s ability to honor the agreement The specific responsibilities of both the patient and clinician Unfortunately, several problems have emerged since their inception in approximately 1973. One of the biggest problems is that there is no solid scientific evidence that they work. Although many studies have been done using NSC (see Rudd et al., 2006; Wasserman et al., 2021, for a review), they have primarily looked at the prevalence of use. Those studies that have attempted to look at utility and effectiveness suffer from serious methodological flaws. Some of the problems with NSC can be summarized as in Table 13.
The information in Table 14 reviews the current use of no suicide contracts (NSC) and suggests there may be problems with this approach especially in terms of their effectiveness (based on Kroll, 2000; Page and King, 2008; Wasserman et al., 2021). As can be seen, even with NSC in place, a very high percentage of patients “under contract” ultimately commit suicide.
Alternatives to the No-Suicide Contract
Various authors (see Rudd et al., 2006; Wasserman et al., 2021) have recommended alternatives to the NSC. The focus of these alternative approaches is on using an agreement (not a “contract”) as a clinical intervention. One such example is the Commitment to Treatment Statement (CTS). The CTS is defined as an agreement between the clinician and patient in which the patient makes a commitment to the treatment process and to living by:
Identifying the roles, obligations, and expectation of both parties Communicating openly and honestly about all aspects of treatment Accessing identified emergency services during periods of crisis
The focus of the CTS is a commitment to living by engaging in treatment and accessing emergency care, rather than removing the suicide option. The authors recommend that the CTS always be handwritten and individualized to the patient (rather than a standardized preprinted form). The agreement might also include a timeframe depending upon the patient’s input. A sample CTS can be found in Table 15 (from Rudd et al., 2006 p. 247).
This type of agreement has a very different “feel” than a no-suicide contract. This “agreement” is focused on the patient and on clinical issues related to treatment. The CTS provides a line for a “witness” signature and this is often a family member. This underscores the importance of involving family members in this process whenever possible. The authors suggest that a copy of the CTS be kept in the chart and one given to the patient. It can be updated and modified as necessary.
The authors also recommend the use of a crisis response plan (CRP) which provides specific instructions for the patient during a state of crisis (See Table 16). They suggest writing the instructions on a 3 X 5 card so that the patient can carry it. As an overview, the first part of the CRP involves self-management skills to enhance crisis management and the final steps include external resources. The therapist should be very specific about what defines a crisis, especially for those who have been chronically suicidal. The CRP can be modified as treatment progresses.
Suicide Management Much of the information in the following does NOT present a treatment guide to suicide management but rather guides for managing suicidal behavioral within any theoretical treatment orientation. This course assumes the clinical skills necessary to manage a suicidal patient given the appropriate guides. Different management strategies are presented but do tend to coalesce into common themes. Lee and Bartlett (2005) and others (See References) outline suicide prevention and management strategies in summarizing five critical elements. These include:
Thorough Assessment of Suicide Risk Much of the course to this point has focused on suicide risk assessment. All of this information is used to develop an appropriate treatment plan and manage the patient in a safe manner. The previous review has included such “tools” as the clinical interview, suicide risk assessment questionnaires, looking at the medical history, talking with other previous treating professionals, talking with family members, etc. The Suicide Intent Checklist was designed by the authors for rapid (and ongoing) assessment of likelihood that the patient will engage in suicide behavior. It is less specific than many of the other guidelines discussed elsewhere but helps to give the clinician an overview of what to be assessing.
In the opinion of these authors, affirmative answers to the first four questions almost automatically dictate a referral for inpatient hospitalization. As we have seen, more detailed assessment, and implementation of risk management procedures may or may not suggest this action. For a number of reasons (e.g. limited resources, diminished insurance benefits, etc.), inpatient treatment of the suicidal patient has decreased.
Establishing an Appropriate Management Plan After completing a suicide risk assessment, a treatment plan is established. Establishment of the treatment plan takes into account a number of issues gathered during the risk assessment. It should be noted that risk management is ongoing during treatment. Some of the treatment possibilities will be discussed subsequently. Assuming the patient does not require hospitalization the following general guidelines should be considered (Lee and Bartlett, 2005)
Involve Family Members and/or Significant Others As will be discussed, allowing family members to control the management of a suicidal patient can result in disastrous results. However, appropriate involvement of family members can be very important. In essence, the therapist will literally have one or two hours with the patient every week. That leaves a lot of hours during the week for suicidal ideation and behavior. Involving family members extends the accuracy of risk assessment as well as the efficacy suicide management.
Consult with Other Professionals It is important to consult with other professionals when managing a suicidal patient. It is only human for a therapist to become emotionally involved (not in an unethical sense) and this can impact objective clinical decision-making. As will be discussed, a common therapist mistake is lack of communication with other professionals, under-treating symptoms, and not taking into account the significance of patient communications. All of these issues can potentially be averted if an objective third party is available for consultation.
Implement the Plan Assuming Professional Responsibility Completing a thorough risk assessment and coming up with a reasonable treatment management plan is worthless unless the information is used appropriately. A common mistake among therapists is to not follow through with their treatment plan (to be discussed). The best laid treatment plan (and risk assessment) is often derailed by such things as allowing the patient to control the therapy, not communicating with other professionals, allowing family members to control treatment, under-treating symptoms, ignoring symptoms “hoping for the best”, etc. (again, all of this will be discussed). The bottom line is that the therapist is responsible for managing the suicidality appropriate to the standard of care and in the best interest of the patients. In this process, there is a strong likelihood you will not be the patient’s friend (in fact, they may “hate” you at times). Even so, achieving the ultimate goal of keeping them alive and achieving therapeutic goals is the end point.
Guides to Assessment and Management of Suicidal Behavioral
There are a number of high quality reviews of the literature relative to suicide risk assessment and management including VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide (2019); Suicide Risk Assessment Guide: A Resource for Health Care Organizations (HCO Guide; Perlman et al., 2011); Advances in the Assessment of Suicide Risk (Bryan and Rudd, 2006), and Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors (APA, 2003) among others. Much of the information in these guides has been reviewed previously. The following is an overview of some of the information presented in these Guides.
Assessment of Suicide Risk The assessment of suicide risk has been covered in detail previously in this course. In fact, the emphasis on risk assessment is the primary focus of one of the guides: Suicide Risk Assessment Guide: A Resource for Health Care Organizations (HCO Guide; Perlman et al., 2011).
As briefly summarized in the Key Points, it is important to specifically assess for suicidality at the initial evaluation and then every follow-up session (if suicidality has been found to be an issue). As discussed previously, adequate assessment of suicide risk involves a number of factors and these have been summarized in Tables 6-10. The details of risk assessment have been reviewed previously and will not be reviewed here. A Decision-Making Framework As discussed previously in this course (See Table 3 for a review), it is important to have agreed-upon terms relative to suicidality. As discussed in the Guides, research suggests that suicide symptomatology fall into two factors: (1) suicidal desire and ideation and (2) resolved plans and preparations. As stated in the Air Force Guide (AFG: page 19 - See Resources), “Although suicidal symptoms and indicators from both factors are important, those that fall into the resolved plans and preparation (RPP) factor are indicative of greater risk.” Some of those factors that fall into the RPP factor include
Sense of courage to make an attempt Sense of competence to make an attempt Availability of means for an attempt Opportunity to make an attempt Specificity of plans for an attempt Preparation for an attempt Duration of suicidal ideation Intensity of suicidal ideation The AFG go on to review risk level determination stratified differently for multiple-attempters versus non-multiple attempters (See page 20; this research is based on Joiner et al., 1997; 1999; See also Wasserman et al., 2021). As stated in the AFG, “Research indicates that persons with two or more suicide attempts are at significantly higher risk for suicide even when there is no acute crisis” (Rudd et al., 2001). Therefore, when determining suicide risk, a lower threshold should be set for those who are multiple attempters. Once a level of suicide risk is determined, an appropriate intervention and management plan can be established. Appropriate responses ranging from management on an outpatient basis with recurrent evaluation (mild risk or less) to immediate hospitalization (severe/extreme risk) can be found in Table 12 and the AFG on page 21.
Outpatient Management Strategies According to the various reviews of the literature, outpatient treatment planning for suicidal patients has been focused on the psychiatric condition and the suicidality has been viewed as a symptom (AFG, p. 22). Best practices now suggest that the suicidality, or potential for self-harm, be viewed as a primary target of intervention rather than secondary to the psychiatric issues (e.g. depression, personality disorder, etc.). Once the treatment plan has been established, ensure that you follow it and document your rationale for ongoing decisions (especially any that deviate from the original plan). One specific way of targeting the suicidal symptoms is through the use of the Crisis Response Plan (CRP, as discussed previously; See Table 16 and AFG, p. 22; A sample CRP can also be found in the AFG Appendices).
Increasingly, suicidal patients are being managed on an outpatient basis. Whether in the hospital, or in an outpatient treatment environment, it is important to safeguard the environment. Several steps are suggested in the literature including removal of any firearms, close supervision of medications, addressing use of an impulse-lowering substances, and assessment of all means of self-harm that a patient has seriously contemplated. The literature acknowledges that it is impossible to limit access to all means of self-harm, but documenting steps to decrease the threat is important. In many cases, this may need to involve family members or significant others to ensure that a patient has followed through on recommendations. If the patient is unwilling to allow their participation (or contact), then a contingency treatment plan might include hospitalization if safety cannot be reasonably established. If a suicidal patient is being managed in the hospital, specific policies and procedures are usually in place. In the special situation of a suicidal patient on a medical floor, please see our course, “Working with Medical Patients”. As discussed in the guides, practitioners should have a “usual and customary” method of managing suicidal patients. This will ensure that appropriate issues are always addressed.
Documentation Strategies Documentation issues are discussed in more detail in a subsequent section. The AFG have a detailed discussion reviewing the literature and providing suggestions for documentation strategies (p. 26). As discussed, “Clinical records are most complete when they document the domains that were assessed related to the suicide, relevant findings, treatment planning specific to the suicide risk factors, and the rationale for decisions made.” (p. 26). The following content for documentation is recommended as often as is clinically indicated:
The patient’s actual statements regarding suicidal thoughts The content of discussions about risk and safety Any outside information provided by family members Any attempts to obtain prior treatment records All increases in treatment intensity or frequency Any special precautions taken or arrangements made Any attempt at voluntary hospital admission All reasons why hospitalization was rejected as an alternative After hours arrangements that have been established
As discussed in the AFG (p. 26), “It is recommended that you include a risk assessment section in every initial note and all follow-up notes for patients who are at moderate risk for suicide.” An example of what might be included in the section can be found in the AFG (p. 26). If a patient is referred to another provider, this must be documented and appropriate follow-up completed to determine that recommendations were followed.
Coordination with Inpatient Care Communication among healthcare providers is one of the biggest problems in managing the suicidal patient (or any other patient for that matter). It is recommended that the practitioner attempt to collect information and stay in contact with other providers as appropriate (e.g. get records from past therapists, ongoing treatment with a psychiatrist, other involved parties). In addition, coordinating with inpatient care is important. For most practitioners, this issue will occur in one of two ways: First, a clinician may have a patient hospitalized on either a voluntary or involuntary basis. In the vast majority of cases for those with primarily outpatient practices, there will be little contact with the patient during the hospitalization (unless you have privileges or get temporary privileges). In this day of managed care and limited resources, hospitalizations for suicidality are brief. In most cases, the patient is stabilized and when the acute crisis and suicidality resolve, he or she is discharged. In these cases, the patient will be discharged with a recommendation that they follow up with their primary treating therapist. Communication with the outpatient therapist can be minimal, at best. When starting to see a patient again, after hospitalization, it is important to get as much information from the hospital as possible. That is the only way to firmly establish your new “starting point” in therapy.
The second situation in which a practitioner might see a patient after hospitalization is referral either from the discharge staff or being selected from some type of Manage Provider Network (MPN). In this case it is very critical to get information from the hospital about the reason for the hospitalization, the course of treatment, status at discharge, etc. You will also need information about other resources provided to the patient (or that s/he has available), the benefits of the insurance for outpatient treatment (before officially accepting the case), etc.
Clinical Support and Peer Consultation If you work in a group treatment setting or HMO model (e.g. Kaiser), clinic support is often readily available. In addition, the sharing of medical records across providers is much easier. In a solo private practice setting, this is more challenging. The provider should ensure appropriate communication with other parties as necessary. In addition, if you do not have much experience in managing suicidal patients, or if some unique issue occurs in treatment, peer consultation is critical. Of course, document that the consultation occurred, the issues discussed, and the conclusions established.
Ensuring Continuity of Care As discussed previously, having a “usual and customary” protocol for managing the suicidal patient is important. One aspect of this protocol should include how to handle patients that drop out of treatment or refuse to follow treatment recommendations. As an example, for patients who do not show up for appointments consistently or “disappear” from treatment one might: make three attempts to contact the patient by phone (to address return to treatment, etc.). If this is not successful, a no-show letter should be sent with appropriate alternatives for the patient (return to treatment, refer to another provider, emergency resources, etc.). Many of these issues are discussed in the course, Difficult Therapy Termination Issues.
Continuity of care also includes ensuring that there is some type of coverage if the provider is away on vacation, or for some reason is not available on an emergent basis. This contingency should be discussed with the patient beforehand.
Lastly, continuity of care must also be addressed if the patient or therapist is moving or, for some reason, a referral to another provider must be made. When helping to establish treatment with another provider, every effort must be made to ensure that a professional relationship has been successfully established with the new clinician and all appropriate information provided. Many of these issues are discussed in the course, Difficult Therapy Termination Issues
Links with the Community and Self-help Focus An ongoing focus in the treatment of the suicidal patients is establishing links to the community and activating resources. One of the issues is after-hours emergencies when the therapist is not available or cannot be immediately located. The patient should be provided with resources in the community that can be called upon in these situations. These might include suicide hotlines, community mental health clinics (although these are becoming rarer), and the location of a local emergency department that can handle mental health issues.
An ongoing focus of treatment should include connecting the patient with sources of support in the community. In dealing with the suicidal patient, this has been termed a Collaborative Model (Ellis, 2004). Ellis differentiates between a Therapist Responsibility Model (TRM), Client Responsibility Model (CRM) and the Collaborative Model (CM). In the TRM, the therapist assumes the role of healer and is viewed as primarily responsible for outcome (p. 42). The TRM is heavily influenced by the medical model in which the clinician does something to the patient to make him or her better. The patient is often viewed as a more passive recipient in treatment. In contrast, the CRM model places almost all of the responsibility on the patient. If he or she does not get better, then there was a lack of taking responsibility for improvement (or being involved in the treatment). This model is also known as the “blame the victim” approach according to Ellis (p. 44). An alternative to the TRM-CRM dichotomy as discussed by Ellis is the collaborative model (CM). In the CM, the responsibility for treatment is shared by the clinician and patient. Questions to be answered throughout treatment include such things as “Have the client and I been truly collaborating?”, “Are we both working hard”, and “Do we both feel responsible for progress”, etc. (from Beck, 1993). Ellis (2004) summarizes general principles for the CM process when working with a suicidal patient. These are summarized as follows:
Self-help orientation from day one. The collaborative mindset should be established with the client from day one (the initial evaluation). Usually, the initial evaluation involves the clinician asking a lot of questions, and the client providing information. This often sets the tone of the practitioner being active and the patient being passive. This approach can easily be modified to include a CM approach. This might include such things as asking the client his or her own assessment of the problem, discuss the client’s ideas for possible remedies, and recommending homework assignments for the client to begin from the outset. The CM approach can be a treatment philosophy throughout the intervention.
Fading directiveness over time. In some cases, the practitioner will have to be more directive in the beginning of treatment due to the client’s inability to be more actively engaged (e.g. the severely depressed). Even so, as the treatment progresses, the shift of responsibility can move to more of one of collaboration. In making this transition, it is appropriate to involve the patient in the process. For instance, instead of assigning the patient a book or book chapter to read, discuss with the patient what he or she feels might be realistic to undertake (e.g. a few pages versus a book, etc.). Using this method, the client is participating not only in the active participation, but also designing how that active participation will take place. Using this method also increases the likelihood of success.
Shifting responsibility for crisis management. According to the CM approach, the therapist may be highly responsible for crisis management initially, but this also should be faded over time. As the patient responds to treatment, there should be appropriate encouragement to rely on other resources to manage crises such as coping skills, family relationships, significant others, etc. Of course, the therapist always remains in the background, if needed. This must be done in an appropriate manner so that the client does not perceive it as any type of abandonment (which it is not). Rather, it is the client taking more responsibility as appropriate.
Transparent agenda. As discussed by Ellis, it is common for a therapist not to share one’s formulation or treatment plan with the client. This makes it difficult for the client to actively participate (collaborate) in treatment and tends to foster the TRM. The CM allows for “few if any secrets between therapist and client, in much the same manner that a personal trainer would discuss strengths, weaknesses, and improvement strategies with a fitness client” (Ellis, 2004, p. 48).
Mutual goal-setting and agenda-setting. Consistent with all of the other tenets of CM, the therapist and client should engage in ongoing goal and agenda-setting. As reviewed by Ellis, goals can be conceptualized in three categories: therapy goals, session goals (agenda), and mini-contracts. Setting therapy goals goes beyond the simple conclusion of “help the client get better.” Setting therapy goals can be fairly involved since those of the therapist and client may differ. As Ellis points out, some clients want to leave suicide open as an option even with ongoing treatment (whether they are willing to specifically mentioned it or not). This is one reason the Commitment to Treatment approach and Crisis Response Plan has been recommended (as discussed previously) over the no-suicide contract. Using this approach (versus the NSC) is consistent with CM and avoids the issue of forcing the client overtly having to commit to something that he or she may not actually be accepting.
Establishing session goals at the beginning of each visit is consistent with CM and many other treatment approaches (e.g. CBT) and CM. This method has been found to increase the client’s involvement in the session and decreases the chances at working at cross-purposes. As pointed out by Ellis, simply asking the patient for his or her agenda for the session is not consistent with this approach. Rather it is a brief collaborative discussion in which the therapist might mention ideas for an agenda and getting the client’s input. The mini-contracting approach includes a collaborative discussion and agreement on short term interventions (even within-session) and goals.
Coach/trainer model. As discussed by Ellis, most patient/clients enter therapy with the conception of the TRM (based on experiences of being treated by other types of doctors). It is recommended that the client can be reoriented and educated about the CM approach through the use of metaphors. One such metaphor suggested by Ellis is that of a coach-trainer. Using this analogy, the client can often understand that the coach (therapist) will provide direction and important resources, but skill acquisition and improvement occur only with active involvement on the part of the student/learner (client). This coach-trainer idea establishes the CM philosophy and approach while contrasting the disease/healer model. A Special Population: Geriatric Patients
Although all of the risk factors and management guides apply to the geriatric population, this does represent a special group. The data demonstrate that there is a bimodal distribution to the suicide curve. The elderly and adolescents are at the highest risk. About 20% of all successful suicides are completed by men over 65 years old with the greatest risk among those over 69 years old. An interesting but as yet unexplained trend beginning in the 1990’s when managed care became prevalent is the increase in the number of successful suicides in men over 80 years old.
About 75% of the elderly who successfully commit suicide had been recently diagnosed with a first episode of major depression which was rated to be only “moderately severe” and a similar number (about 75%) had seen their family doctor within one month of the completed suicide.
Although all of the risk factors previously discussed apply to the elderly (predisposition to suicide, current factors, protective factors), there are some that are more prevalent. These are listed in Table 20. Any clinician working with the elderly should be aware of these characteristics.
Among the elderly, detecting suicidality and preventing suicide is more challenging since they may tend to be more reserved about the symptoms (e.g. sharing emotional distress), making a cry for help (e.g. instrumental suicide-related behavior) and being more serious in their attempts (gunshot, hanging, lethal overdose with no chance of discovery).
When suicidality in an elderly individual is suspected, the special risk factors should be assessed carefully. Talking with the patient’s family is also important since 60% of individuals who commit suicide have discussed suicidal ideations with family members within the past year. In stark contrast, only 18% discuss their intentions with a healthcare professional.
One of the most important factors is the accurate identification of depression in the elderly. Many healthcare professionals will miss the telltale signs of depression in the elderly (or disregard them), believing they are “normal” signs of aging. Depression presents differently in the elderly than in other populations. The elderly individual with depression often presents with fewer mood-related symptoms and instead complains of fatigue, concentration difficulties, diminished memory, and lack of initiative. In at least one study, depressed patients were more likely to deny sadness and/or lack of pleasure in activities formerly enjoyed. This is referred to as “masked depression” or “nondysphoric depression” (See Table 21).
Due to the unusual presentation of depression in the elderly, special assessments have been developed such as the Modified Koenig Depression Scale (See Table 22). As can be seen, the items are specific to how depression tends to present in the elderly. The Modified Koenig Depression Scale was originally developed on medically ill patients in the Veterans Administration Hospital. Using an oral presentation format with males and females, the Koenig has been found to have a sensitivity of 100% and a specificity of 85% for detecting depression using DSM criteria.
Assessment of the elderly person with depression (and suicidality) should determine whether it is more lifelong (most major depression begins with a first episode in the person’s 30’s) or whether it is late onset. If the first episode of major depression occurs after age 65 then it is referred to as late-onset or geriatric-onset depression. This category of depression is well-known in the literature but is not specifically identified in the DSM. Late-onset depression has different characteristics than a lifelong pattern and these can be found in Table 23.
Treatment Treatment of depression (and suicidality) in the elderly is similar to that with other populations including cognitive behavioral therapy (CBT), or some other psychotherapy interventions, individual/family treatment, and appropriate medications. In treating the elderly, there are some important issues when choosing an antidepressant. The selective serotonin reuptake inhibitors (SSRI) are commonly used. These medications have shown a low incidence of side effects, few cardiac effects, and are generally effective for treatment of depression in the elderly. It has been shown that patients who have an actual psychiatric consultation for their depression (for medications) do better. Even with a high rate of mental illness among the elderly, they tend to underutilize mental health services. It is estimated that only 2% of the elderly see a private psychiatrist and only 6% receive any services from community mental health programs. Reasons for this under-utilization include the stigma of seeing a mental health professional, problems with transportation, and not knowing that the resources are available. Clinicians working with the elderly in any setting should keep these issues in mind.
Suicide in the Patient without Depression The euthanasia program in Oregon provides data relative to a unique population, mostly elderly: those patients who want to die and are not depressed. Part of the physician-assisted suicide program screening is that the patient be free of depression. Given the unique characteristics of this euthanasia population, the following are reasons given for desiring suicide (See Table 24):
Some of this information may be useful in assessing the depressed elderly person. In the research, psychiatric nurses listed the following issues as important reasons for patients deciding on euthanasia: lack of control, loss of independence, pain relief, concern about becoming a burden to one’s family. Thus, in patients without identified depression, overriding issues of loss of physical function and declining health seemed to be related to suicidality. Importantly, the patient’s perception of being a burden (and the other issues) were rated as more severe than those of the significant others’ ratings of the same issues. This data is important since it can alert the clinician to other suicidality issues even in patients who do not present with the classic depression symptoms.
Injured Workers and Increased Risk for Suicide
People suffering serious workplace injuries often face ongoing physical and mental health issues, but new research suggests their situations outside of work may be even more dire. An injury severe enough to keep an employee home for at least a week almost tripled the combined risk of suicide and drug overdose death among women, and raised that risk 50% among men, according to a new study.
Serious workplace injuries are associated with increased risks of both suicide and death related to opioid overdose, according to a recent published in the American Journal of Industrial Medicine (Applebaum et al., 2019). The findings suggest that serious on-the-job injuries may be one factor that explains the uptick in suicides and overdose deaths nationally. “This study suggests that serious work-related injuries may contribute to the alarming rise in deaths from both opioid overdoses and suicide,” said lead author Kate M. Applebaum, ScD, MSPH, an associate professor of environmental and occupational health at the George Washington University Milken Institute School of Public Health (Milken Institute SPH). “We must continue to advance research to better understand the relationships between workplace injury, opioids and mortality. In addition, better treatment of the pain, substance use disorders and depression that often go along with workplace injuries may reduce this mortality risk.”
Applebaum and her colleagues studied more than 100,000 workers in New Mexico from 1994 through 2000, including 36,034 who had suffered an occupational injury serious enough to require a week off from work. The researchers looked at a combination of data on worker compensation injuries, Social Security earnings and mortality data, and cause of death from the National Center for Health Statistics. Workers were followed post-injury for up to 20 years in order to study long-term mortality trends. The study found that these serious workplace injuries nearly tripled the risk of suicide and overdose death for women and raised the risk by about 50 percent for men. They found that men with a lost-time injury were 72% more likely to die from suicide, and 29% more likely to die from drug-related causes. Women were even worse off; those with lost-time injuries were 92% more likely to die from suicide, and 193% more likely to die from drug-related causes. The report did not offer an explanation as to why women suffered such worse outcomes, considering that overall, more American men die from opioid overdoses than women. And while more women attempt suicide, men are more likely to die from it, according to the American Foundation for Suicide Prevention — although that gap is closing between boys and girls. Limitations of the study included only looking at workers in one state. The data provided also didn’t identify mortality risk factors that the workers had before their injuries, such as underlying diseases, BMI and whether they used drugs, cigarettes, or alcohol. Drug overdoses and suicides have been rising in the United States for about a decade. Many experts blame the opioid crisis for these so-called “deaths of despair,” but this is the first study to link these deaths to workers who had serious job injuries. Previous studies have linked serious workplace injuries to both depression, which can trigger a suicide attempt, and the use of opioid painkillers, Applebaum said. Given these new findings, injured workers on disability are likely a higher risk population for suicide and clinicians need to be aware of this data.
Learning from our mistakes
It is beyond the scope of this course to review all of the clinical methods related to the clinical management of suicidality within the context of treatment. In fact, beyond assessing and monitoring risk as discussed previously, the treatment intervention can take many forms depending on the therapist’s orientation. An important question, regardless of treatment orientation is,
“What mistakes do therapists make that directly relate to preventing a patient from committing suicide?”
Please see the following references relative to mistakes made by therapists when working with the suicidal patient: Ellis et al., 2018.; Rothes and Henriques, 2018;Wasserman et al., 2021. Much of the information in these articles is summarized in the following:
In an informative study (the only one of its kind), Hendin et al. (2006) examined 36 cases of patients who died by suicide while receiving open-ended psychotherapy and medication. In the study, the therapists of the 36 patients completed a number of questionnaires and wrote detailed narratives about each case. The therapists then participated in an all-day workshop during which critical problems were identified. According to the authors, six recurrent problem areas were identified and these are as follows. Each of the problems identified is discussed given the information presented in this course.
Lack of Communication between Therapists In nine of the cases a lack of communication between therapists created serious problems. Twenty-three of the patients had been involved in treatment with another therapist before beginning treatment with the therapist during which they died. In all of these cases, communication between current and previous therapists was rare. In three cases, after the patient’s death, a former therapist shared information that might have resolved an impasse in treatment. In two other cases, the patient was hospitalized just before the suicide. The lack of communication between the hospital staff and the outpatient therapist resulted in misjudgments about the patient’s suicide risk.
As discussed by the authors, the lack of communication was most striking in four cases. In these cases, a psychotherapist (social worker or psychologist) was providing treatment concomitantly with a psychiatrist (a very common occurrence). In one case of a patient being treated concomitantly at the same institution, the psychiatrist and social worker had electronic access to each other’s treatment notes but did not communicate directly. The social worker was aware that the patient was not taking his medication and that family problems were worsening. The patient was encouraged to take his medication and agreed he would not commit suicide while his parents were alive (“he couldn’t do that to them”). In his last session with the psychiatrist nine days before the patient’s death, he admitted fantasizing about shooting himself. The psychiatrist considered hospitalizing the patient but accepted his promise that he would not kill himself.
The day before the suicide, the patient met with the social worker. He was distressed about family issues but continued to state he would not kill himself “while his parents were alive”. The social worker offered more frequent sessions and telephone support. The patient killed himself the next day. During all of this time, the psychiatrist and social worker did not speak directly.
Case discussion. In these cases, it is simply unknown as to how the outcome might have been different if the various providers had engaged in direct communication. Certainly the potential to prevent a suicide might have been enhanced. Direct discussion with past and current treaters is important to complete all elements of suicide risk assessment and management. It is also good clinical practice. Not communicating with others involved in the patient’s care (past and present), could be negligent under many of the “Failure to…” categories discussed previously.
Permitting the Patient or Their Relatives to Control Therapy In 17 cases, therapists allowed the patient or the patient’s relatives to control the therapy. On occasion, suicidal patients will attempt to control the course of therapy using the threat of suicide to do so. In the study, the authors found that in 3 cases, the patient set certain criteria for living and insisted on the therapist’s support in meeting those conditions. In each of those instances, the therapist complied, believing that doing so was necessary to keep the patient alive and in treatment.
In one case, a man with bipolar disorder agreed not to kill himself if he was successful in opening a business in the next 6 months. His condition for continuing treatment (and living) was that the therapist help him convince his parents to provide financial support for the business. The therapist agreed and several treatment sessions included the parents. Although the parents agreed, several problems occurred and the business did not open on schedule. The patient became very agitated and distressed, and the therapist suggested hospitalization. The patient declined but “agreed to think about it”. The therapist did not take any further action. The patient hanged himself that night.
In two cases, the patients subtly exerted control by continually alluding to various topics during the course of therapy and then refused to discuss them. Since the patients were potentially suicidal, the therapists accepted this behavior to avoid upsetting them. In 9 cases, the patients determined whether and in what amounts they would take their medication. The lack of adequate medication treatment seriously compromised the therapy, but the therapists continued, feeling they had no choice. In 3 inpatient cases, relatives were allowed to control critical aspects of the treatment that likely compromised suicide assessment and management. In one case, a patient was given a day pass after the therapist was pressured by a family member. The patient killed himself while out on pass. In two cases, after pressure from family members, the patients’ discharged planning was accelerated against the therapists’ better judgment. Both patients killed themselves in the hospital just before discharge.
Case discussion. In these cases, the patients and family members were allowed to control critical aspects of the suicide risk assessment, management, and overall treatment. Even with the best understanding of suicide risk assessment and management, unless adequate implementation is completed, the data is worthless. When patients and family members attempt to control treatment in a deleterious fashion, it most often represents acting out of the pathology in question. The therapist in these situations (especially the patient wants to control treatment “or else…..”) should definitely seek outside consultation, keep one’s focus on the established assessment and treatment methods, and decide when the patient is simply not willing to commit to treatment (see the course on Difficult Therapy Termination Issues related to patient’s responsibility in treatment).
Therapist Avoidance of Issues Related to Sexuality In 7 of the cases, issues related to sexual conflict were clearly avoided by the therapists. The issues largely involved patients’ ambivalence and conflicts about homosexuality. In most of the cases, the therapists were aware of the issues, but they were rarely specifically brought up and addressed in the therapy. In one case, a never-married man in his late 30’s with major depressive disorder, suicidal ideation, avoidant personality disorder, and substance abuse was receiving therapy for long-standing conflict about homosexual behavior (he was raised by repressive, Catholic parents). The patient had several homosexual encounters in his 20’s but was currently searching personal ads for a girlfriend, which was not successful. He discussed in therapy that a co-worker often teased and humiliated him which was “enraging.” The therapist believed the co-worker was implying the patient was homosexual, but the patient refused to discuss it in therapy and the therapist did not pursue it. During what was ultimately to be his last session, the patient came in angry and refused to sit down. Standing at the door, the patient announced that he was “fed up” and “finished” with work and therapy and was “getting out now.” The therapist urged the patient to discuss what had happened but the patient refused, left the session, and stated that he would see her next week. He killed himself the next day.
Case discussion. The case discussed in detail represents one of what appears to be a chronic baseline risk due to the number of potentiating risk factors (see Tables 6 and 12). In treating a patient with these baseline potentiating factors (static), one must always be aware of a rapid emergence of warning signs or entering an acute exacerbation state. In this case, we do not know if the patient ever overtly expressed suicidal ideation (possible “hidden ideator”), however there were many other identifiable risk factors. We also do not know if these were specifically assessed or monitored by the therapist. The patient’s behavior at the last session, especially given all of the potentiating factors, would represent a rapid emergence of multiple warning signs.
Ineffective or Coercive Actions Resulting from the Therapist’s Anxiety In 11 of the cases, the therapist’s anxiety over the possibility of suicide interfered with their ability to treat their patients effectively. In three of the cases, the patients made their intent to commit suicide clear, but the therapists felt unable to intervene or seek consultation. In 5 cases, the patients expressed suicidal intent and the therapists suggested hospitalization but left the decision to the patient. In each case, the patient rejected the suggestion and committed suicide shortly thereafter.
In three other cases, the therapists’ anxiety led to actions that were harmful to treatment. In one example, presented in the article, a man had been hospitalized for over a year for major depressive disorder and avoidant personality disorder without improvement. He demanded ECT treatment and attempted to electrocute himself on more than one occasion. In response, a frustrated treatment team had him sign a contract to stop the behavior and threatened early discharge. The patient overtly complied. To reward his compliance, he was allowed to go on a staff-supervised outing from which he escaped and killed himself. After the patient’s death, a note in the chart revealed that the patient had told a staff member that his compliant behavior had been an act. The contract and threat of early discharge caused the patient to suppress his frustration over his lack of treatment and set up a power struggle which the patient “won” by committing suicide.
Case discussion. In the first cases discussed in this section, the therapists apparently did not take appropriate action even when it was clearly indicated. When suicidality reaches the severe to extreme level (see Table 12), immediate evaluation for inpatient hospitalization is indicated (either voluntary or involuntary). In these cases, the decision is not left to the patient.
In the case discussed in detail, some of the problems related to no-suicide contracts are portrayed (as discussed previously). In this case, the contract seemed to act as a blockade to the patient being able to discuss his frustration over his lack of progress in treatment. One wonders how this case might have been turned out if a therapeutic risk management approach had been taken along with a commitment to living (treatment) agreement rather than a “contract” and threat of early discharge. This last case also underscores the previous discussion about lack of communication. Even though, charted (as discovered after the patient’s death), one wonders how the case might have been managed if the staff knew the patient was simply complying overtly.
Not Recognizing the Meanings of Patients’ Communications In 9 of the cases, the meanings of the patients’ communications were not recognized by the therapists. In one case that exemplifies the problem, a therapist was working with a middle-aged man with a history of bipolar disorder and suicidal ideation who became intensely anxious and unable to function socially or at work. The patient called his therapist to tell her that he had accidently taken a double dose of his medication. He asked her if she thought he had made an inadvertent suicide attempt. She assured him that he had not. He killed himself later that week. In retrospect, the patient’s question was communicating an increased preoccupation with suicide that was left unaddressed.
Case discussion. The case presented in detail again underscores the importance of assessing potentiating risk factors that establish a suicide risk baseline. Against this “baseline” all future “warning signs” or acute exacerbations can be judged. As discussed in this course, patients will not always present a clean set of data indicating that an acute phase is being entered. However, any small warning sign can signal the therapist to immediately and directly assess other risk factors. In this case, if the therapist had accepted the patient’s conclusion that it might have been an “inadvertent” suicide attempt, more aggressive assessment of warning signs might have been completed along with appropriate intervention.
Untreated or Undertreated Symptoms In 17 cases, the patient exhibited major symptoms related to substance abuse, anxiety, and/or psychosis, but these problems were not adequately addressed in treatment. As the authors point out, the most striking example was 11 patients who had active substance abuse problems which were not treated. In 15 cases, the patient’s intense anxiety in the period preceding the suicide was not adequately treated. In 3 other cases, the patients presented with clear psychotic symptoms that were either undiagnosed or untreated.
Case discussion. In all of these cases, one wonders what the outcome might have been if a suicide risk assessment had been completed along with appropriate monitoring. The presence of substance abuse (active) is always a concern given the lowered impulse control. It also appears that the emergence of “intense anxiety” may not have been adequately assessed and treated as it was a prodrome to acute exacerbation of suicidality.
These cases exemplify what can happen if suicidality is not assessed and managed properly. As Hendin et al. (2006, p. 70) point out,
“Therapists’ fear that a patient may commit suicide frequently impeded their ability to deal effectively with the danger. Paradoxically, we have found that therapists who recognized that a patient was in suicide crisis are often shocked when the patient actually kills himself or herself suggesting that some therapists deal with that anxiety by denying that what seems possible, or even likely, could actually happen.” Documentation
The level of suicide risk should be clearly documented along with information to support this assertion. There is no “gold-standard” in terms of this type of documentation; however, the suicide risk assessment should address important variables as outlined in Table 6 and the protective factors as outlined in Table 10, along with the clinician’s reasoning supporting treatment decision-making (Table 12). Any methods used to complete this assessment should be documented such as clinical interview, suicide risk questionnaires, interviews with family members, discussions with other treaters, etc. The documentation should also include a discussion of baseline suicide risk factors (or “predisposing” or static variables) along with acute symptoms (warning signs) that may or may not be present. It is also important to document protective factors since these will tend to attenuate the suicide risk and are often the focus of ongoing treatment. The following case examples demonstrate documentation for suicidality in mild risk and severe risk cases. The format has been adapted from Bryan and Rudd (2006) and others (See References and Resources).
Case example of mild risk. This is a 55-year-old male construction worker who was injured on the job approximately 10 years ago. He had always been a hard worker, being in the field for over 25 years prior to his injury. He continued to work after the injury until a spine surgery. He has been totally disabled for the past 8 years due to back pain. He is married with two children. His wife has had to return to work to help support the family. The patient lost his home due to financial problems. He has been battling various agencies to get approved for disability support. His previous suicide behavior (5 years ago) occurred in response to being turned down for various treatments and disability support. He had no psychiatric history prior to the injury but has been in treatment for depression since then.
Case example of severe risk. The patient in Table 24 is adapted from Bryan and Rudd (2006). This is a 46-year-old twice divorced female who is in her third marriage which she describes as “happy” (or “…at least better than the first two”). She currently works part-time and cares for her two teenage children (one from each previous marriage). She has a long history of an eating disorder (currently active) and a history of being sexually abused as a child by an uncle. She has a history of suicide attempts (three occasions before 25 years old by overdose) but she never told anyone. She constantly “worries” and feels guilty about the eating disorder and abuse history. Stress includes work and family. She feels “worthless” and like she will “never live up to her potential.” She drinks alcohol and smokes marijuana to help with her stress. Her social support is minimal outside of her immediate family. She has a very strained relationship with her family of origin and little contact with them. She revealed that her husband keeps a gun in the house “for protection.” When asked about a plan, she was vague but stated that, “if things become too bad, I could just shoot myself.” The patient has never had contact with a mental health professional.
Summary and Conclusions
The following Table summarizes some of the important issues in suicide risk assessment and management. Using a therapeutic risk management approach, suicidal risk assessment and management is integrated into good clinical care.
If a practitioner determines a patient to be suicidal, precautionary measures such as involuntary or voluntary commitment for observation may have to be invoked; although, in some cases, using sound clinical judgment, the suicidal patient may be most appropriately managed on an outpatient basis. As long as the standard of care is commensurate with community standards and the treatment decision is in the best interests of the patient, there would be no grounds for negligence if the patient is treated in the “least restrictive” environment and appropriate suicide risk management is ongoing.
Resources
VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide (2019; 190 pages)
Suicide Risk Assessment Guide Ontario Hospital Association. (2011; 122 pages)
American Psychiatric Association (2010). Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors (123 pages).
Stop a Suicide (stopasuicide.org)
American Association of Suicidology (suicide.org).
Air Force Guide for Managing Suicidal Behavior: Strategies, Resources, and Tools
Air Force Guide For Managing Suicidal Behavior: Appendices
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