SUICIDE: RISK AND ASSESSMENT

MICHAEL J. ADELMAN MD PGY3

YOUR PATIENT
She is a 12 year old female who presents to you in clinic 4 days after being seen at PCMC with suicidal ideation and a plan to overdose on OTC pills. She was assessed to be of low acute risk in the ED and given an outpatient referral to behavioral health which has been followed up by phone and she has an appointment with a therapist in 3 weeks. She is not endorsing an SI over the last 4 days today in clinic and her mother has been watching her closely at home. What else do you want to know

PMH
Genu Varum deformity since birth with corrective hardware. She has had difficulty with pain and decreased mobility this past year. She has had a recent weight gain of 50lbs in the last 6 months that she attributes to increased appetite and decreased activity. Physical exam in clinic today is notable for moderate obesity, surgical scars, but otherwise nonfocal.

SH
She attends school at a local middle school, is in the 7th grade, gets all As Endorses several close friendships at school, well connected with peers She is a singer and a clarinet player, in band and choir She enjoys playing basketball as well, but has done less of that recently. Parents divorced 7 months ago and she has struggled with this, lives with mom currently and sees Dad mostly on weekends, but does not ever stay with him. No experimentation with EtOH or drugs

FH
Paternal history of drug abuse and alcoholism Maternal history of depression and hypothyroidism

PSYCH HX
No previous therapist or psychiatrist No previous psychiatric diagnosis Over the past 6 months, meets criteria for major depressive disorder without significant anxiety or other psychiatric symptoms.
Mood low Sleeping more - always tired Regular feelings of guilt and worthlessness Decreased energy Decreased concentration/focus Appetite increase weight gain as previously noted Suicidal Ideation

SUICIDE
Third leading cause of death in adolescence (15-19 years) Increased 300% from 1950-1990, but has since been in modest and continual decline with 35% reduction from 1990-2003. Completed suicide is six times as prevalent in males, while attempted suicide is twice as likely in females Ratio of attempted to completed suicides in all youth is estimated to be between 50-100:1 Firearms are the leading cause of completed suicide in males (54%) and second in females (29%) Ingestion is the most common form of completed suicide for females and the most common attempted form overall

SUICIDAL IDEATION
From Nock et al in JAMA Psychiatry in 2013

One-third (33.4%) of ideators go on to develop a suicide plan, and 33.9% make an attempt. The proportions of ideators who go on to make an attempt are 60.8% of those with a plan compared with 20.4% of those without a plan, This results in roughly 60% of first attempts being planned (57% among boys and 66% among girls) and the other 40% unplanned.

SUICIDE RISK ASSESSMENT (SRA)

Connectedness

Impulsivity/Access

Disconnectedness

KNOWN RISK FACTORS

Fixed
PREVIOUS SUICIDE ATTEMPT Family history of suicide/attempt Male gender Parental mental health problems Gay/Bisexual orientation History of physical/sexual abuse Presence of Firearms in the home Impaired parent/child relationship Living outside the home (institution, group home, correctional) Difficulty in school/not attending school/not working Social Isolation Stressful life events (romantic, legal, family related)

Social/Environmental

Mental Health

Depression Bipolar Disorder Substance Abuse or dependence PTSD Panic attacks History of aggression/impulsivity/anger control issues More than 90% of adolescent suicide victims meet criteria for a psychiatric disorder

WHICH RISK FACTORS ARE MOST IMPORTANT?

Slap et al published in Pediatrics in 1989 attempting to answer this question and develop a tool for rapid screening of adolescents. They used a case control analysis of 56 adolescents admitted for medical complications of a suicide attempt vs. 248 adolescents admitted for other reasons Subjects submitted self-administered questionnaires

RESULTS?

ANYTHING ELSE?
Borowsky et al published another study in Pediatrics in 2001 using data from the National Longitudinal study of Adolescent Health (1995-1996) Study attempted to retrospectively examine factors related to suicide attempts

RESULTS?
3.6% of this national sample attempted suicide with attempts highest in Hispanic and white females (5.5% and 5.6%) Used logistic regression to delineate what variables were statistically significantly associated with suicide attempt

RISK FACTORS

PROTECTIVE FACTORS

MY FAVORITE TABLE

WRAPPING UP

QUICK WORD ON SSRIS

2004 black box warning for suicidality (based on meta analysis of 24 clinical trials with 4% spontaneous endorsement of suicidality in treatment group and 2% in placebo group) Contradictory finding of slight reduction in suicidality when subjects responses to serial visits were analyzed (considered overall more reliable than spontaneous event reports) Prescriptions for adolescents decreased by nearly 20% the following quarter. Concomitant increase in suicides of 18.2% from 2003-2004 after years of steady decline. (unclear of origin) Treatment for Adolescents with Depression Study (TADS)

increased suicide related events in fluoxetine group (p<0.04 with OR of 3.7) Also with concomitant decrease across all groups in suicidality over 12 weeks of treatment and improvement in depression in both the medication group and medication+psychotherapy. Only 5 suicide attempts (2 combination, 2 fluoxetine, 1 CBT, 0 placebo) in the trial with no completions.

CAUTIOUS OPTIMISM

SUICIDE RISK ASSESSMENT (SRA)

Connectedness

Impulsivity/Access

Disconnectedness