MORNING REPORT SUICIDE ASSESSMENT 11/2/2011

Kyle Smith, MD, PGY-5

Case Presentation

ID: 15 yo male with a history significant for ADHD presents to the ER due to safety concerns. He is accompanied by his mother. CC: My depression is coming out as anger.

HPI

1-2 months with a decline in mood No particular stressor identified Per mother, low mood manifests with irritability Increasing intensity of anger

Punched a door yesterday, and a wall last week

Mother has worried about depression since pt was 8 yo Father committed suicide, pt never really talked about it Crying more the last few weeks Sleeps up to 12 hours nightly Poor motivation for most tasks

More HPI

Gave mother a note last week

Repeatedly

wrote, I am nothing, and at the end, he wrote, I am a disappointment. No mention of self harm in the note Pt describes note as a cry for attention.

No hx of self harm, occasional thoughts of death with no plan Mother discussed the note with a counselor earlier on day of presentation, and was advised to come in for evaluation

Filling in the Gaps

First year in high school, failing a number of classes, poor attendance Has experimented with both alcohol and cannabis Recent change in friends in relation to change in school

Reviewing Psychiatric Symptoms

Depression: Denies anhedonia; energy intact Mania: No symptoms Anxiety: Describes self as laid back. Not a worrier. Says he is terrible in large social situations Attention: Long-standing inattentiveness; distractible; no hyperactivity Psychosis: No symptoms Conduct: Skips classes; no fights; no running away; no cruelty to animals; legal problems substance-related Substance Use: Alcohol since age 14, drinks to get drunk; cannabis since age 14, was smoking daily

Psych History

Diagnoses: ADHD, inattentive type Meds: Adderall, helped sx but appetite suppression Treatment: Went to The Sharing Place after fathers death; visited often with the school counselor at his old school Hospitalizations: None Suicide Attempts: None

Other Histories

Medical: Healthy; no hospitalizations or surgeries Family History

Father

had depression, attempted suicide once, and then killed self by hanging Mother with mild depression, doing well on Cymbalta

Development: Normal

Social History

Generally a C student, worse grades this year

Skipping a lot of class

Heterosexual, sexually active Several guns at home; mother keeps weapons and ammo separate and locked Large number of opioid analgesics at home for mother Many knives at home

Mental Status

Appearance: Good hygiene; in hospital gown; right hand rather bruised Attitude/Behavior: Cooperative, more so when mother not present; looks down often Speech: Monotone, normal volume Mood: Im depressed. Affect: Constricted Thought Process: Linear Thought Content: No active suicidal ideation Cognition: Oriented; memory grossly intact

What is the next step?

This was an ER setting, but this young gentleman very well could come into a primary care clinic

Level of comfort with making a disposition decision?

Suicide Facts

Youth Suicide in 2007 (ages 10-24 yo)

Nationwide, 4320 deaths

Third leading cause of death Age 20-24: 12.5/100K Age 15-19: 6.9/100K Age 10-14: less than 1/100K

Male youth die by suicide 5x more frequently than females Race: Native American highest at 14.8/100K; Caucasian next highest at 7.3/100K 45% of deaths by firearm, 38% by suffocation

http://www.suicidology.org/web/guest/stats-and-tools/fact-sheets: Select Youth Suicidal Behavior

Even ask the little ones

OLeary et al, J Dev Behav Pediatr, 2006: Suicidal ideation among urban nine and ten year olds. There remains a relative paucity of research on the prevalence of suicidal ideation and intent in children younger than 12 years of age.

131 children, 51% with in utero cocaine exposure, largely African American population Suicidality assessed using Childrens Depression Inventory, with affirmative responses to the statement, I think about/want to kill myself. 14.5% of children with suicidal ideation

Suicidality was associated with depressive symptoms, exposure to violence, and distress symptoms in response to witnessing violence

Prenatal exposure was not a significant association.

Risk Factors for Completed Suicide

Mental illness and substance abuse 90% of adolescent suicides occur in individuals with a pre-existing psychiatric disorder Previous suicide attempts But, only 1/3 have a previous known attempt Firearms in the household Non-suicidal self injury Exposure to a friends or family members suicidal behavior Low self-esteem Other risk factors for attempts: Abuse history; LGBT http://www.suicidology.org/web/guest/stats-and-tools/fact-sheets: Select Youth Suicidal Behavior sexual orientation (not associated with completed

Protective Factors (not a complete list)

Family connectedness and school connectedness Reduced access to firearms Safe schools Academic achievement Self-esteem

http://www.suicidology.org/web/guest/stats-and-tools/fact-sheets: Select Youth Suicidal Behavior

Quick and Easy Screen

SADPERSONS
Sex (Male > Female) Age (Bimodal, adolescent/young adult & elderly) Depression (Mood disorder) Previous attempt Ethanol abuse (or any substance) Rational thinking loss (think psychosis) Social support lacking Organized plan No spouse Sickness

Current UNI Risk Assessment

Rather Extensive History of suicidal thoughts or behaviors

Ideas; plans; attempts; lethality; intent Ideas; plans; attempts; lethality; intent

Current suicidal thoughts or behaviors

Psychological features

Anger; hopelessness; decreased self esteem; humiliation; shame; agitation; psychosis; intoxication
Recent stressful events; lack of social support; possible social support; poor relationship with family; sense of responsibility to family; domestic partner violence Access to firearms, medications, or other means of suicide; poor or positive therapeutic relationship

Psychosocial features

Additional features

Something more feasible

Risk of Suicide Questionnaire

Established from the work of Horowitz et al, Pediatrics, 2001: Detecting Suicide Risk in a Pediatric Emergency Department: Development of a Brief Screening Tool

Given to 155 children and adolescents presenting to the ER with psychiatric chief complaints 14 screening questions were given, and the validating criterion standard was the SIQ

SIQ= Suicidal Ideation Questionnaire, 30 items, fee for use, good tool but pretty burdensome Has been previously plugged by Doug Gray

A positive response to any question constituted a positive screen for suicide riskgood sensitivity, not so good specificity

A Handy Screening Tool?

Mean age 13.6 years, SD 2.5 years Little improvement in predictive ability was obtained beyond the inclusion of 4 RSQ questions Thus, the predictive abilities of every possible four question combination were assessed The following four questions had a sensitivity of 0.98 (for a positive SIQ)

1) Are you here because you tried to hurt yourself? 5) In the past week, have you been having thoughts about killing yourself? 8) Have you ever tried to hurt yourself in the past other than this time? 13) Has something very stressful happened to you in the past few weeks?

Takeaway: If your get a positive here, more detailed assessment is warranted

Before Sending Off

Checklist before discharge for adolescents who have attempted suicide

Caution

patient and family about disinhibiting effects of drugs or alcohol Check that firearms and lethal medications can be effectively secured or removed Check that there is a supportive person at home Check that a follow-up appointment has been scheduled
http://aacap.org/cs/root/member_information/practice_information/practice_parameters/practice_parameters: Select Suicidal Behavior (Of note, an update is in progress!)

Means Reduction

Effective because many suicide attempts are made impulsively

15-34 yo patients following a near-lethal suicide attempt, 24% reported the interval between deciding to commit suicide and making the attempt was less than 5 minutes!

JAMA review in 2005: Data needed across the board to support prevention strategies, but did support two interventions

Physician recognition and treatment for depression

Means reduction

Correlation data (spanning 1986-2002) exists on decreased guns in US homes and declines in suicide rates.

Will the effect last? Britain and carbon monoxide example

Johnson R, Coyne-Beasley T. Lethal means reduction: what have we learned. Current Opinion in Pediatrics. 2009;21:635-640

The relative infrequency of suicide, in conjunction with ethical concerns and the population-level of many lethal means reduction initiatives pose significant barriers to using trials to evaluate means reduction.

The Safety Contract

AACAP: Limitations must be considered when using a nosuicide contract. Initially, the no-suicide contract was to serve as an assessment tool

If they refuse to sign, thats pretty telling

Contracting for safety with patients: clinical practice and forensic implications. Garvey et al, J Am Acad Psychiatry Law, 2009.

Research on the effectiveness of contracting for safety with adolescents in reducing suicide risk is minimal. Regarding medicolegal implications: It appears that frequent contact and ongoing assessment on the part of the psychiatrist led to a favorable legal outcome rather than the use of a pact.

Several cases reviewed in which a contract did nothing to reduce liability.

So what do you do?

Pragmatic thoughts from an admitted amateur

Listen

to the patient, but a little skepticism is okay Listen to the parents Dont worry alone
Outpatient

Follow Up

PCMC Behavioral Health Intake: 801-313-7711 U of U Child Psych Clinic: 801-585-1212

Crisis

Eval

PCMC ER; UNI Crisis (801-583-2500, ask for the CAC)

Document

your reasoning