Suicide Assessment and

Prevention in a
Multidisciplinary Model
Paul Zarkowski MD
Clinical Assistant Professor
Department of Psychiatry and Behavioral Sciences
University of Washington

Senior Psychiatry Supervisor

Sound Mental Health
 Financial Disclosure
• Paul Zarkowski MD has no financial relationships to
disclose relating to the subject matter of this
presentation.
 Section 1
History of Community
Mental Health
Before Community Mental Health

Western State Hospital

Main hospital building, 1892
 Dean Brooks MD
1916 - 2013

MGM via Photofest, https://www.nytimes.com/2013/06/01/arts/dean-

brooks-cuckoos-nest-doctor-dies-at-96.html, accessed 12/9/2022
Creation of Community Mental Health

Sound Mental Health

Building A, 1976
Sound Mental Health Today
 Section 2
Suicide Assessment
 Suicide Assessment
Step 1
• One single question • Một câu hỏi duy nhất
• Critical point for • Điểm mấu chốt để tư
referral in primary care vấn về chăm sóc sức
khỏe ban đầu
• Organized plan
• How much time is spent • Kế hoạch có tổ chức
thinking about suicide? • Đã dành bao nhiêu thời
• Preparations? gian để nghĩ về việc tự
• How organized? tử?​​
• Rehearsal? • Có sự chuẩn bị?​
• Tổ chức như thế nào
• Diễn tập như thế nao ?​
 Case Fatality Rate per Agent
USA, 1989-1997
Drug/Poison

Jump

Cut/Pierce

Firearm

Drowning

Suffocation/Hanging

Poison by Gas

Other

0 20 40 60 80 100

Case Fatality Rate (%)

Spicer RS and Miller TR. Am J Public Health. 2000;90(12):1885-1891.

 Case Fatality Rate by Pesticide
Korea1, India2 and Sri Lanka3

Paraquat

Yellow Phosphorus

Dimethoate

Fenthion

Chlorpyrifos

0% 10% 20% 30% 40% 50% 60% 70%

1Lee JW et al J Korean Sci 2015 Oct; 30(10): 1517–1521 2Venugopal R et

al. J Gastroint Dig Syst 2018 8.3 3Eddleston M et al. Lancet 2005 Oct 22-
28;366(9495)
 Case Fatality Rate by Medication
USA, 2011-2012
Opioids

Barbiturates

Antidepressants

Antidiabetic

Salicylate

Psychostimulant

Antiepileptic

Benzodiazepine

Ibuprofen

0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00%

Miller TR et al. JAMA Network Open 2020 3(3) e200607 Data

shown are for 2012 dataset.
Time to Completed Suicide after Initial Attempt
USA, 1986-2007

Bostwick JM et al. American Journal of Psychiatry 2016

https://doi.org/10.1176/appi.ajp.2016.15070854
 Similar Findings Reported Worldwide

• 90 studies
– UK and Ireland 30%
– Scandinavia & Finland
26%
– Rest of Europe 19%
– North America 11%
– Australia & New Zealand
8%

Owens D et al. British Journal of Psychiatry 2018 181:193-9

 Suicide Assessment
Step 2
• Based on entire
interview
• Future orientation
• How much do they care
about the things in their
life?
• Meaning and purpose?
• Compare with any
suicidal ideation
• Dựa trên toàn bộ cuộc
phỏng vấn
• Định hướng trong
tương lai
• Họ quan tâm về những
thứ trong cuộc sống của
họ nhiều như thế nào?​
• Ý nghĩa và mục đích?​
• So sánh với bất kỳ một
ý tưởng về tự sát nào
 Suicide Assessment
Step 3
• Risk factors • Các yếu tố rủi ro
identified in được xác định từ
numerous sources nhiều nguồn
• Reversible factors • Các yếu tố có thể
• Irreversible factors đảo ngược
• Risk variation in • Các yếu tố có thể
triple digits không đảo ngược
• Biến đổi rủi ro tăng
gấp 3 lần
 S.A.D. P.E.R.S.O.N.S.
(Kỹ Thuật Ghi Nhớ Cho Người Học Tiếng Anh)​
S: Male sex S: giới tính nam
A: Older age A: tuổi lớn hơn
D: trầm cảm
D: Depression
P: đã từng thực hiện
P: Previous attempts E: lạm dụng chất cồn
E: Ethanol abuse R: mất đi tư duy suy nghĩ hợp lý
R: Rational thinking loss S:không có hỗ trợ từ những quan
S: Social supports lacking hệ
O: Organized plan O: kế hoạch có tổ chức
N: không có vợ/chồng
N: No spouse
S: bệnh tật
S: Sickness
 Suicide Incidence
by Sex and Region
2019
20

15

10
/100,000
5

0
Africa Americas South-East Asia Europe Eastern Western Pacific
Mediterranean
Male Female

World Health Organization,

https://apps.who.int/gho/data/node.main.MHSUICIDEASDR?lang=en,
accessed 10/8/2022
 Suicide Incidence
by Age, Sex and Race/Ethnicity
USA 2019-2020

Ehlman DC et al. Mobidity and Mortality Weekly Report 2022 Feb 25 Vol 71(8)
 Odds Ratio of Suicide
By General Medical Condition
Canada, 1992-2000
Severe Pain (2.51-6.59)

Bipolar Disorder (1.57-8.18)

Depression (3.27-4.75)

Psychosis and Agitation (1.93-3.50)

Anxiety and Sleep Disorder (2.27-4.75)

Seizure Disorder (1.42-4.07)

Moderate Pain (1.04-1.47)

Congestive Heart Failure (1.00-1.85)

Chronic Obstructive Lung Disease (1.06-1.58)

Dyslipidemia (0.32-0.60)

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5

Juurlink DN et al. Arch of Int Med 2004;164(11):1179-1184

 Odds Ratio of Suicide
By General Medical Condition
Taiwan, 2002-2012
Mood Disorder (7.06-7.79)

Psychotic Related Disorder (5.63-6.53)

Anxiety Disorder (2.57-2.81)

Substance Use Disorder (2.51-3.20)

Cancer (1.77-1.98)

Cerebral Vasular Disease (1.26-1.40)

Chronic Kidney Disease (1.11-1.35)

Diabetes Mellitus (1.16-1.26)

Hypertension (0.85-0.91)

Dyslipidemia (0.72-0.80)

0 1 2 3 4 5 6 7 8

Liu CH et al. Journal of Cardiac Failure 2018 Nov;24(11):795-800

 Odds Ratio of Suicide
By Month After Cancer Diagnosis
Taiwan, 2002-2012

Wang SM et al. International Journal of Cancer 2018 May 15;142(10):1986-1993

 Odds Ratio of Suicide
By Psychiatric Condition
Japan, 2006-2009
Major Depression (3.45-11.2)

Dysthymic Disorder (0.35-7.30)

Brief Psychotic Disorder (0.71-8.29)

Panic Disorder (1.25-24.4)

Generalized Anxiety Disorder (1.18-8.13)

Alcohol Dependence (1.58-8.58)

Alcohol Abuse (1.07-19.7)

Drug Dependence (0.63-14.7)

0 1 2 3 4 5 6 7

Hirokawa S et al. Journal of Affective Disorders 2012 Oct;140(2):168-75

 Suicide Incidence
By Marital Status, Sex and Age
USA, 1978-1981
Males Females

Smith JC et al. American Journal of Public Health, 1988 Vol 78 No 1

 Odds Ratio of Suicide
By Marital Status, Sex and Age
Norway, 1991-2012

Oftedahl Naess E et al. SSM Population Health 2021, Vol 15. 100853
 Odds Ratio of Suicide
By Days from Separation
Norway, 1991-2012
14

12

10

0
0-30 31-92 93-183 184-365 >365
Male Female

Oftedahl Naess E et al. SSM Population Health 2021, Vol 15. 100853
 Odds Ratio of Suicide
By Marital Status, Sex and Age
Taiwan, 1997-2003
Males Females
Married Never Married Divorced Widowed 6

5 5

4 4

3 3

2 * 2
* * * * *
1 1 * * *
0 0
<35 35-50 51-64 >64 <35 35-50 51-64 >64

*Confidence Interval includes 1.0- not significant.

Hey JY et al. Suicide and Life-Threatening Behavior 38(3) June 2008

 Odds Ratio of Suicide
Marital Status, Sex and Social Support
China, 2005 - 2008
Males
18
16
14 Females
12 12
10 10
8 8
6 6
4 4
2 * 2 *
0 0
*
No Yes Yes No <32 32-37 >37 No Yes Yes No <32 32-37 >37

Married Living Alone Social Support Married Living Alone Social Support

*Confidence Interval includes 1.0- not significant.

Zhang J et al. American Journal of Psychiatry 2010 167(7) 773-781

 Integration of Risk Factors
P = b1x1 + b2x2 + b3x3 + b4x4 + b5x5 + b6x6 + b7x7 + b8x8 + b9x9 + b10x10

• Determines safe limit in • Xác định giới hạn

balance between an toàn cân bằng giữa
ideation and future ý tưởng và quyết
orientation định trong tương lai
 Section 3
Validating the Risk
Rescue Rating
 Risk Rescue Rating
• Risk Factors
• Agent used
• Impaired consciousness
• Lesions/toxicity
• Reversibility
• Treatment required
• Rescue Factors
• Location
• Person initiating rescue
• Probability of discovery by
any rescuer
• Accessibility to rescue
• Delay until discovery
Weisman AD & Worden JW. Arch Gen Psychiatry. 1972;26:553-560.
• Các yếu tố rủi ro
• Những chất đã sự dụng
• Suy giảm ý thức
• Thương tổn/độc tính
• Sự đảo ngược
• Sơ đồ điều trị cần thiết
• Các yếu tố để giải cứu
• Địa điểm
• Người bắt đầu giải cứu
• Xác suất phát hiện ra
bởi người cứu hộ
• Khả năng tiếp cận để cứu hộ
• Trì hoãn cho đến khi
tìm được
 County of Residence
of Suicide Completers
100
90
80
70
60
50
40
30
20
10
0
King County Neighbor County Distant County Out of State
Hotel Population General Population

Zarkowski P & Avery D. Suicide Life Threat Behav. 2006;36:578-581.

 Purpose of Hotel Visitors
King County from Out of Town

Business

Convention

Pleasure/Vacation

Visit Friends &

Relatives
Other

2003 Market Profile and Economic Impact of Seattle-King County Visitors, CIC
Research, San Diego, 2004
 Purpose of Hotel Visitors
Local Residents of King County

? House Remodel

? Pest Control

Romantic Getaway

? Early AM Flight

? Domestic
Turbulence
 Hotel Room Suicide
King County 2002-2004
• Out of town visitors1
5 cases
(31,655 rooms)(61.7%)(2.3/room)(3 yr)(0.94)
=3.7 cases of suicide/100,000
Relative risk 0.365 compared with national rate, p<.01
• Local residents2
14 cases
(31,655 rooms)(61.7%)(2.3/room)(3 yr)(0.06)
=173 cases of suicide/100,000
Relative risk 14.8 compared with county rate, p<.0001
 Hotel Room Suicide
Las Vegas (Clark County)
• 145,000 hotel rooms
• 88% occupancy
• Relative risk vs gen. pop.
• Local county residents
• 16.3, p<.0001
• Out of county visitors
• 0.377, p<.0001

Gemar K, Zarkowski P & Avery D. Soc Psychiatry Psychiatr Epidemiology

2008;43:25-27.
 Method of Suicide
Las Vegas
Guns

Hanging

Drugs

CO

Cutting

Medication

Jumping

Asphyxia

Other

0 10 20 30 40 50 60
General Population Hotel Population

Gemar K, Zarkowski P & Avery D. Soc Psychiatry Psychiatr Epidemiology

2008;43:25-27.
 US Multiple Cause of Death
Register
60
• Increased suicide risk in Clark
50 County
• Odds of suicide is 50% greater for residents
40
of Clark County, compared to residents
All Other elsewhere at home
30 Deaths
• Visitors to Las Vegas are at double the risk
Suicide
compared to those that stayed home or
20 visited other counties
• Leaving Clark County was associated with a
10
20% decline in odds of suicide, compared to
those that stayed home
0
Visitors Home

Wray M et al. Social Science in Medicine. 2008;67(11):1882-1888.

 Possible Confounds
• Replicated in Orange County, Fl.
• Increased risk in residents
• Decreased risk when residents left county
• Risk increased in travelers to OC compared to
other counties, but not compared to those
that stayed home.
• Clark County Coroner Data
• 33 visitors committed suicide in a hotel over a
3-year period
• 27 visitors were in a site other than a hotel
• 8.3 cases/100,000 people

Zarkowski P & Nguyen D. Social Science in Medicine. 2012;74(10):1471-1473.

 Hotel Room Suicide
Wayne County
• Multivariate logistic regression1
• Divorce, hanging, substance abuse and
out of county residence.
• After correcting denominator2
• Relative risk vs gen. pop.
• Local county residents, 27.0,
p<.0001
• Out of county visitors, 0.524,
p<.05
• Three visitors traveled to see
Dr. Jack Kevorkian for physician
assisted suicide

1Wasserman I & Stack S. Death Studies. 2008 32(8):757-67

2Zarkowski P, Dever R & Avery D. Primary Care Companion CNS Disorders. 2019

21(4).
 Hotel Room Suicide
Travis County, Texas
• Relative risk vs gen. pop.
• Local county residents
• 16.4, p<.0001
• Out of county visitors
• 0.193, p<.01
• Method of suicide
• Risk ratio of gunshot
wound
• 0.27, p<.01

Zarkowski P, Dever R & Avery D. Primary Care Companion CNS Disorders. 2019
21(4).
 Hotel Room Suicide
Cuyahoga County
• 2nd smallest number of
hotel rooms in sample,
15,394 units
• Relative risk vs gen. pop.
• Local county residents
• 15.1, p<.0001
• Out of county visitors
• 0.176, p<.0001

Zarkowski P, Dever R & Avery D. Primary Care Companion CNS Disorders. 2019
21(4).
 Hotel Room Suicide
Orange County
• 2nd largest number of
hotel rooms in sample,
53,697 units
• Relative risk vs gen. pop.
• Local county residents
• 37.8, p<.0001
• Out of county visitors
• 0.124, p<.0001

Zarkowski P, Dever R & Avery D. Primary Care Companion CNS Disorders. 2019
21(4).
 Incidence of Suicide
350

300

250 King
Clark
200
Wayne
/100,000 150 Travis
Cuyahoga
100
Orange
50

0
True Visitors General Population Local Residents

Zarkowski P, Dever R & Avery D. Primary Care Companion CNS Disorders. 2019
21(4).
 Method of Suicide
5
4.5
4
3.5
King
Risk Ratio, 3 Clark
Hotel vs 2.5 Wayne
General 2 Travis
Population Cuyahoga
1.5
1 Orange

0.5
0
Gunshot Wound Hanging Drug Toxicity

Zarkowski P, Dever R & Avery D. Primary Care Companion CNS Disorders. 2019
21(4).
 Marital Status
4

3.5

3
King
Risk Ratio, 2.5
Clark
Hotel vs 2 Wayne
General
1.5 Travis
Population Cuyahoga
1
Orange
0.5

0
Single Married Divorced Widowed

Zarkowski P, Dever R & Avery D. Primary Care Companion CNS Disorders. 2019
21(4).
 Section 4
Clinical Management of
the Suicidal Patient
 Patient Management
Establish and Maintain a
Therapeutic Alliance
• Barriers • Một số rào cản
• Patient may view • Bệnh nhân đôi khi cho r
psychiatrist/therapist ằng các bác sĩ tâm lí và
as an adversary. các nhà trị liệu là người
• False/unrealistic hopes xấu
• Countertransference • Những hy vọng sai và
thiếu thực tế
• Phản di chuyển hướng
cảm xúc
American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric
Disorders: Compendium 2006. American Psychiatric Publishing; 2006.
 Attend to Patient Safety
• Observation and • Quan sát và theo dõi
monitoring • Loại bỏ những đồ vật có
• Removing potentially thể gây thương tích
hazardous items hoặc có hại

American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric

Disorders: Compendium 2006. American Psychiatric Publishing; 2006.
 Determine a Treatment Setting
• Least restrictive • Những môi trường ít
environment, yet safe hạn chế nhưng an toàn
and effective và hiệu quả
• Hospitalization • Nhập Viện
• Outpatient Care • Chăm sóc ngoại trú
• Balanced with, • Được cân bằng với
• Disrupted employment • Gián đoạn công việc
• Financial stress • Căng thẳng tài chính
• Social stigma • Kỳ thị xã hội

American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric

Disorders: Compendium 2006. American Psychiatric Publishing; 2006.
 Develop a Treatment Plan
• Mix of biological and
psychosocial therapies
• Address substance use
• Ongoing possible
modification of plan with
change in suicidal
ideation and behavior
• Kết hợp giữa trị liệu sinh
học và trị liệu tâm lý xã
hội
• Bàn về lạm dụng các chất
• Các sự thay đổi đang xảy
ra về kế hoạch để thay
đổi suy nghĩ và những
hành vi liên quan đến tự
tử

American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric

Disorders: Compendium 2006. American Psychiatric Publishing; 2006.
 Collaborate with Other Clinicians
• Clear role definitions
• Regular communication
among team members
• Advance planning for
management of crises
• Clarify team approach
with patient
• Định nghĩa vai trò rõ ràng
• Thường xuyên giao tiếp
với mọi người trong đội
• Lên kế hoạch nâng cao để
đối phó với khủng hoảng
bất ngờ
• Vạch rõ cách tiếp cận của
đội đối với bệnh nhân

American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric

Disorders: Compendium 2006. American Psychiatric Publishing; 2006.
 Promote Adherence to Plan
• Create atmosphere in
which patient is free to
disclose feedback
• For meds, explain;
• May take weeks for
benefit to show
• The need to continue
once symptoms recede
• What to do if questions
emerge
• Tạo bầu không khí phù
hợp để bệnh nhân trao
đổi ý kiến
• Đối với thuốc men, hãy
giải thích rằng:​
• Có thể phải chờ vài tuần
để thấy các lợi ích của
thuốc
• Tiếp sử dụng thuốc kể cả
khi các triệu chưng đã
giảm
• Làm gì khi các vấn đề xảy
ra​

American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric

Disorders: Compendium 2006. American Psychiatric Publishing; 2006.
 Patient and Family Education
• Goals
• Mental illness is real
• Role of psychosocial
stressors
• Course is not linear
• Identify signs of relapse
• Family history of suicide
does not make suicide
inevitable
• Các mục tiêu
• Bệnh về tâm lý là có thật
• Vai trò của sự căng thẳng
về tâm lý
• Khóa học không
tuyến tính
• Phát hiện những dấu
hiệu của việc tái phát
• Tiền sử gia đình về tự
sát không làm cho việc tự
tử khỏi xảy ra

American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric

Disorders: Compendium 2006. American Psychiatric Publishing; 2006.
 Antidepressants and Suicidal
Behavior

• Swedish Health Registry

• All patients 6 to 59 yo started on an SSRI between 2006 to 2013
• Rate of completed suicide was 68.7/100,000 after initiation of tx.

Lagerberg T et al. Neuropsychopharmacology 2022 Mar;47(4):817-823

 Antidepressants and Suicidal
Behavior by Age

Lagerberg T et al. Neuropsychopharmacology 2022 Mar;47(4):817-823

 Antidepressants and Suicidal
Behavior by Medication

All analyses were adjusted for time varying treatment with non SSRI
antidepressants and benzodiazepines. Strongest correlation was for
benzodiazepines with IRR of 1.71 (1.58-1.86)

Lagerberg T et al. Neuropsychopharmacology 2022 Mar;47(4):817-823

 Lithium
• Decreases both attempts • Giảm tỉ lệ tự tử thất bại
93% and completed 93% và tự tử thành công
suicides 82% 92%​
• Unipolar > Bipolar II > • Trầm cảm Unipolar
Bipolar I > Bipolar II > Bipolar I​
• Meta Analysis of 34 • Phân tích tổng hợp từ 34
studies1 nghiên cứu1​
• No similar effect for • Không có bất kì hiệu ứng
depakote, lamotrigine or nào tương tự đối với các
carbamazepine chất như: depakote,
lamotrigine hoặc
carbamazepine​

Baldessarini RJ et al J Clin Psychiatry 2003; 64(suppl 5):44–52

 Clozapine
• Reduction in
suicide attempts with
high degree of success
from 5 to 0 in 88
neuroleptic resistant
patients
with schizophrenia
after starting clozapine1
• 83% reduction in in
mortality from suicide in
current users vs past
users of clozapine2
1Meltzer HY & Okayli G. American Journal of Psychiatry 1995; 152:183–190 2Walker AM
et al. Epidemiology 1997; 8:671–677
• Giảm các ca tự sát bất
thành với mức độ thành
công cao từ 5 giảm xuống
0ở
88 bệnh nhân tâm thần
phân liệt kháng thuốc an
thần sau khi bắt đầu sử
dụng clozapine1
• Giảm 83% tỷ lệ tử vong
do tự tử ở người đang sử
dụng clozapine2 và những
người từng sử dụng trong
quá khứ
 Cognitive Behavioral Therapy
• Correct negative
thoughts and behaviors
• 9 systemic reviews and
meta-analysis
• Decreased suicide
attempts
• RR 0.77 (0.69 to 0.87)
Wu H et al. J Affective Disorders 2022 Aug 27;S0165-0327(22)00923-5
• Chấn chỉnh các suy nghĩ
và hành vi tiêu cực
• 9 bài đánh giá có hệ
thống và phân tích tổng
hợp
• Giảm tỷ lệ tự tử bất
thành
• RR 0.77 (0.69 to 0.87)​
 Dialectical Behavioral Therapy
• Prioritizes suicidal behavior
and other self directed
violence
• 18 controlled trials
• Reduced self directed
violence
• d = -.379 (-.581 to -.176)
• No significant effect on
suicidal ideation
• d = -.229 (-.473 to .016)
DeCou CR et al. Behavioral Therapy 2019 Jan;50(1):60-72
• Ưu tiên tập trung cho các
hành vi liên quan đến việc
tự sát và các biểu hiện có
thể gây thương tích cho
bản thân
• 18 buổi thử nghiệm có
kiểm soát
• Giảm bạo lực tự hướng cá
nhân
• d = -.379 (-.581 to -.176)​
• Suy nghĩ về tự tử không có
thay đổi nhiều
• d = -.229 (-.473 to .016)​
 Section 5
Efficacy of
Harm Reduction
 CO from Coal Gas
England and Wales

Kreitman N, Br J Prev Soc Med, 1976 June; 30(2) 86-93

 Ban of WHO Class I Pesticides
Sri Lanka 1995

Gunnel D, Int J Epidemiol 2007; 36:1235-1242

 Ban on Paraquat
Korea 2012
• Ban on manufacture
and import 2011
• Total ban on use
2012
• Decrease in suicide
attempts without an
increase in attempts
with other types of
pesticides3

Lee JW et al J Korean Sci 2015 Oct; 30(10): 1517–1521.

 Suicide Barriers on Bridges
USA
• Two adjacent bridges in
Washington DC
• Ellington and Taft
• Average of 4 deaths/year
by jumping
• After installation of
effective barriers on the
Ellington in 1986, no
increase in suicide on Taft
bridge1
• Aurora Bridge, Seattle
• Previous to installation of
barriers in 2011, was #2 in
USA in number of bridge
suicides2
1Carroll
PW & Silverman MM. Suicide and Life-Threatening Behavior 1994;24:89-99
2Zarkowski P American Journal of Psychiatry 2008 Sep;165(9):1126
Thank you.