Mental health & crisis management 7 APRIL qui z

“The goal of a suicide assessment is not to predict suicide, but rather to...appreciate the basis for suicidality, and to allow for a more informed intervention” - (Jacobs, Brewer, & Klein-Benheim, 1999, p. 6).

 

The assessment of suicide risk is commonly based on the identification and appraisal of warning signs as well as risk and protective factors that are present. Information relevant to the person’s history, chronic experience, acute condition, present plans, current ideation, and available support networks can be used to understand the degree of risk.

 

Suicide risk assessment is a multifaceted process for learning about a person, recognizing and addressing his or her needs and stressors, and working with him or her to mobilize strengths and supports. While suicide risk assessment tools are a part of this process, these should be used to support the assessment process, rather than to guide it. 

 

Risk factors and warning signs

 

Risk factors may be associated with a person contemplating suicide at one point in time over the long term, whereas warning signs are those factors that, in the immediate future (i.e., minutes and days), may set into motion the process of suicide (Rudd, 2008). Warning signs present tangible evidence to the clinician that a person is at heightened risk of suicide in the short term; and may be experienced in the absence of potentiating risk factors.

 

It is important to recognize that risk may still be high in persons who are not explicitly expressing ideation or plans, searching for means, or threatening suicidal expressions. Persons who may be truly intent on ending their lives may conceal warning signs. Thus, it is vital that all warning signs are recognized and documented during the risk assessment process

 

Protective factors

 

Protective factors are those that may mitigate risk of suicide.

 

· Strong connections to family and community support

· Skills in problem solving, coping and conflict resolution

· Sense of belonging, sense of identity, and good self-esteem

· Cultural, spiritual, and religious connections and beliefs

· Identification of future goals

· Constructive use of leisure time (enjoyable activities)

· Support through ongoing medical and mental health care relationships

· Effective clinical care for mental, physical and substance use disorders

· Easy access to a variety of clinical interventions and support for seeking help

· Restricted access to highly lethal means of suicide

 

Principles of risk assessments 

Principle 1: The therapeutic relationship

 

The primary principle for maintaining a person-centered risk assessment is the establishment of a therapeutic relationship with the person (APA, 2003). This relationship should be based on active listening, trust, respect, genuineness, empathy and responding to the concerns of the person (RNAO, 2009). Maintenance of openness, acceptance, and willingness to discuss his or her distress can help minimize feelings of shame, guilt, and stigma that the person may experience.

 

 

 

Principle 2: Communication and collaboration

 

Effective communication and collaboration are crucial for ensuring that suicide risk assessment remains thorough, consistent, and effective in addressing a person’s risk throughout his or her journey through the system (e.g., from the emergency room to the community, from one professional to another). Communication and collaboration are essential for obtaining collateral information about a person’s distress and maintaining his or her safety. To support the person throughout his or her recovery process, it is essential to maintain good communication and collaboration:

· With the person;

· With the person’s informal support network; and

· Within and between the care teams supporting the person.

 

Principle 3: Documentation in the assessment process

 

Documentation is a key process for ensuring the efficacy of suicide risk assessment. After initial and ongoing assessments, chart notes should clearly identify the person’s level of risk (based on warning signs, potentiating factors, and protective factors) and plans for treatment and preventive care. Chart notes should be augmented with structured assessments, including relevant risk assessments, previous psychiatric history, previous treatment received, and concerns expressed by family or friends. In settings where behaviours can be easily observed (e.g., hospital), documentation should also include information about the person’s specific thoughts and behaviours to further help appraise risk.

 

Documentation should include information about current and historical suicidal and purposeful self-harming expressions. Even if the expressions occurred several years previously, it is necessary to explore the circumstances around that incident and the person’s reaction to it, in case a similar situation arises. For both current and historical suicidal expressions, details about timing, method, level of intent, and consequences of the expressions should be documented.

 

Documentation during transitions Studies have shown that persons who have been discharged from in-patient psychiatric care are at particularly higher risk of suicide than the general population (Ho, 2003; Hunt et al., 2009; Goldacre et al., 1993). The transition from the safety of the hospital setting back into the community is a vulnerable period. Discharge planning may improve this transition to the community and reduce the risk for suicide once the person has left in-patient psychiatric care.

 

 

A thorough suicide risk assessment is essential when considering the timing of discharge. If the crisis has not been addressed, the person has not fully de-escalated, or the person cannot (or will not) agree to formulate a safety plan, try to negotiate a safety plan with the person. Suicidal ideation, low mood or hopelessness should not be present at time of discharge. Offer concrete choices (e.g., “Do you think staying in hospital would be helpful, or would returning home with a family member feel safer?”) to provide autonomy to the person to choose the treatment/discharge option that feels most safe for him or her. Relying on how the person has previously managed in the community (or while in hospital) is not a fail-safe indicator of how he or she will respond when back in the community. The person will need preparation for reintegrating, crisis contact numbers, and a timely appointment with a professional to address these items. Persons who self-discharge following a suicide crisis should be red-flagged for close monitoring. Follow-up appointments should incorporate the same suicide risk management practices as those used for discharge planning (Bergmans et al., 2007; Hunt et al., 2009).

 

Persons in hospital or the emergency department for suicidality should be discharged with a specific safety plan on how to stay safe once he or she returns to the community. Strategies for staying safe, early warning signs, grounding techniques, coping strategies and crisis contact numbers that were discussed during the intervention should be included in the safety plan.

 

Principle 4: Cultural awareness

 

Clinicians and health care professionals performing suicide risk assessments need to be aware of culture and its potential influence on suicide. In some cultures for instance, suicide is considered taboo and is neither acknowledged nor discussed. This creates a challenge not only for the clinician assessing for suicidality, but also for the person of that culture who may be struggling with suicidal thoughts and unable to discuss or disclose those thoughts or feelings to members of their same ethnic community. It should be considered a sign of strength for persons whose culture does not accept or discuss suicide to disclose suicidal ideation. Intra-cultural beliefs regarding suicide can be further confounded by age (e.g., youth, adult, elder), sex, and/or religious beliefs.

 

It is important to consider and be aware of this diversity in beliefs and the potential impact on risk of suicide. Whenever possible, talking with the person, family, or others about specific cultural beliefs toward suicide will aid the risk assessment process and help develop an approach to prevention with the person that is in line with his or her beliefs.  

 

It is estimated that 90% of people who die by suicide are experiencing depression, another mental health illness, or a substance use disorder, all of which are potentially treatable (Government of Canada, 2016). About 15% of patients who have major depression or bipolar disorder (during the depressed phase) will die by suicide (Brendel, Breezing, Lagomasino, et al., 2016). Loss of relationships, financial difficulty, and impulsivity are contributing factors in this population.

 

Suicide risk is 50 times higher among patients with schizophrenia than among the general population, especially during the first few years of the illness, and suicide is the leading cause of early death among those with the illness. About 40% of all patients—and 60% of males—with schizophrenia attempt suicide at least once. Up to 10% of these patients die by suicide, usually related to depressive symptoms rather than to command hallucinations or delusions. The more risk factors that are present, the higher is the risk for suicide.

 

Patients with alcohol or substance use disorders also have a higher suicide risk. Comorbidity of substance abuse and depression or antisocial personality disorder is also associated with increased risk. Up to 15% of those with alcohol or substance abuse die by suicide (Sadock, Sadock, & Ruiz, 2017).

Approximately every 40 seconds, a human life ends as a result of suicide (World Health Organization, 2014). Nursing students and practising nurses at all levels encounter individuals suffering from the pain and hopelessness that all too frequently culminate in some type of suicidal expression. These individuals can be identified in inpatient settings, in outpatient treatment settings, and in the community. Studies have shown that 83% of people who die by suicide had received inpatient or outpatient health services in the year before their death (Ahmedani, Simon, Stewart, et al., 2014), with 45% consulting a primary care physician within a month before death (Turecki & Brent, 2016). This highlights the important role clinicians have in identifying risks and preventing these suicides. 

  

The term bullycide was coined by Marr and Field (2000) to refer to suicidal expressions in response to bullying. In a larger survey across Canada it was found that 1 in 5 teens has seriously considered suicide in the last 12 months, with twice as many girls as boys reporting having considered suicide. Of this group, nearly half reported that they did not speak to anyone about suicide (47%) and that they had formulated a plan (46%).

 

Bullying, relationship problems, and body and self-image problems are all related to suicidal thoughts in this group ( Kids Help Phone, 2016 ).