# Presentation: 264709

## Enhancing Student Safety Through Better Suicide Risk Assessment

- Presented by
- Paul Quinnett, Ph.D.
- QPR Institute

## The Purpose of Suicide

- “The common purpose of suicide is to seek a solution.  Suicide is not a random act.  It is never done pointlessly or purposelessly.  It is a way out of a problem, a dilemma, a bind, a crisis, an unbearable situation.  It has an inexorable logic and impetus of its own...  Every suicide makes this statement: ‘This far, and no further.’”
- 			Edwin Scheidman, Ph.D.

## International Perspective 

- World Health Organization
- 	-2001: one million died by suicide
- 	- By 2020: 1.5 million will die by suicide
- 	- In the top 10 causes of death in every country
- 	- Depression is second only to infectious disorders in terms of premature disability and death
- China: 287,000 per year; 1 every two minutes

## American Numbers2002 Data

- 31, 655 in 2002
- Rate: 11.0 per 100,000
- 87 per day (one commercial jet every other day)
- One person every 17 minutes
- Of the 31,655 deaths
- 4 X male completions to female
- 3 X females to male attempts
- 	Suicide is no respecter of age, race, religion, social or economic status; its an equal opportunity mode of death.

## Numbers that Matter

- Think, plan, attempt, die
- 10 million adults think about suicide each year
- 1.2 million plan a method (gun, MVA, etc)
- 750,000 attempt (minimum count).
- Less than 30,000 die
- Suicide is 11th cause of death overall
- 	- 3rd for young people
- 	- first for young people in some states
- 				source: CDC and NIMH

## Not counting intentional life-threatening behavior...

- “There are many ways of killing yourself without killing yourself.”
- 		Tony Manero (John Travolta)
- 				in *Saturday Night Fever*

## 		 PERSONAL PERSPECTIVE

Question: “Why did this patient die by suicide?”

Fatality reviews

		Psychological autopsy

					Method

						Motive

							Opportunity

People or systems?

- Question: “Why did this patient die by suicide?”
- Fatality reviews
- 		Psychological autopsy
- 					Method
- 						Motive
- 							Opportunity
- People or systems?

## IOM: Reducing Suicide, 2002

- “Most people who complete suicide had contact with a health professional within a year of death, and 40 percent of these contacts were within one month of their death.  Many people die by overdose on the prescription medications provided them at these visits.”
- Since most suicides are premeditated, are these missed opportunities?

## Problems in Primary Care

- Between 50-70% of depressed persons first seek help from a PC provider and 30% or more of suicide victims and attempters visit a personal physician within a month of the event
-  Early recognition of depression and suicidal thinking, coupled with appropriate treatment, significantly reduces morbidity and mortality.

## Problems in Primary Care

- There is little reported disclosure of suicidal symptoms to non-psychiatric physicians
- Some feel that patients may perceive PC physicians as being more superficial and less interested in this issue than mental health providers
- Many PC providers reportedly lack confidence in their ability to manage suicidal patients and in the training they have received

## Summary

- It is not known to what degree intervention on this “last contact” might prevent suicide
- Older adults have the highest rates of “last contact” and, therefore, provide the greatest opportunity for intervention
- Alternative approaches are needed for identifying those who make no contact
- Luoma, Martin and Pearson, Am. J. Psychiatry, 2002

## References on Request

- Andersen, S.M., and Harthorn, B.H. (1989).  The recognition, diagnosis and treatment of mental disorders by primary care physicians.  Medical Care, 27: 869-886.
- Coombs, D.W, et al. (1992).  Presuicide attempt communications between parasuicides and consulted caregivers. Suicide and Life Threatening Behavior, 22: 289-302.
- Hirschfeld, R., et al.  (1997).  The national depressive and manic depressive association consensus statement on the under treatment of depression.  Journal of the American Medical Association, 277(4): 333-340.
- Miller, M.C., Paulsen, R.H. (1999). Suicide assessment in primary care settings. In Jacobs, D.G. (ed.). The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco: Jossey-Bass.
- Orleans, C.T. (1985).  How primary care physicians treat psychiatric disorders: a national survey of family practitioners. American Journal of Psychiatry, 142(1): 420-432.
- Rand, E.H., Badger, L.W., and Coggins, D.R.  (1988).  Toward a resolution of contradictions. Utility of feedback from the GHQ.  General Hospital Psychiatry, 10: 189-196.
- Moscicki, E.K. (1999). Epidemiology of suicide.  In Jacobs, D.G. (ed.).  The Harvard Medical School Guide to Suicide Assessment and Intervention.  San Francisco: Jossey-Bass.
- Gliatto, M. F. and Rai, A. K. (1999). Evaluation and treatment of patients with suicidal ideation. American Family Physician 59: 1500-1506.
- Katon, W., and Schulberg, H.C., (1992). Epidemiology of depression in primary care. General Hospital Psychiatry. 14: 237-247.
- Kaplan, M.S., Adamek, M.E., and A. Calderon. (1999). Managing Depressed and Suicidal Geriatric Patients: Differences Among Primary Care Physicians. The Gerontologist: 39(4):417-425.
- Uncapher, H., Arean, P.A. (2000). Physicians are less willing to treat suicidal ideation in older patients. Journal of the American Geriatric Society 48: 188-192.

## Seven Questions

- What are your current beliefs about suicide?
-  Is patient suicide ever a medical error?
- Do near misses count?
- Does safety come first?
- Do current systems promote errors?
- What is the acceptable error (suicide) rate?
- Who’s working on behalf of patient safety?

## Problems in Mental Health

- Suicide risk continues to go undetected (PBHC)
- Assessment failures account for 70% of “medical errors” associated with patient suicide
- Lack of specific training
- Lack of specific knowledge
- Lack of supporting policies & payments
- Reliance on junk science
- Wrong beliefs, e.g., If they really want to kill themselves you can’t stop them.

##     THREE BASIC “MEDICAL” 
ERRORS?
TYPE 1: Failure to detect suicide risk

TYPE 2: Failure to assess and reassess suicide risk

TYPE 3: Failure to establish and monitor a suicide risk management plan

- ERRORS?
- TYPE 1: Failure to detect suicide risk
- TYPE 2: Failure to assess and reassess suicide risk
- TYPE 3: Failure to establish and monitor a suicide risk management plan

## Key terms         ... it is rocket science

- Systems approach
- Forced functions
- Failure Mode Effect Analysis (FMEA)
- Error proofing
- Why? vs. What if?
- Root Cause Analysis (RCA)
- QI and Report to Governance

**Notes:**
Forced function: can’t not do it – QPRT on inside facing sheet
FMEA prevent problems before they happen, required for low volume incidents
   (lunar lander)
Training includes : failure mode effect analysis

## Managing up

- CEOs are often kept in the dark about organizational risks (why ask for punishment?)
- What do you expect of your managers to report regarding suicide risk management?
- 	- concern - % of our admits are suicidal
- 	- non-fatal attempts w/o medical attention
- 	- non-fatal attempts w/ medical attention
-    - fatal attempts: active patient? Discharged?

## 
	Ignorance increases risk; what we don’t know, we don’t do.

- 	Ignorance increases risk; what we don’t know, we don’t do.

## 		Pre-Test Results by Job Title (N=1,100)

**	****	****Pre-Test Results by Job Title (N=1,100)**

## 		Post-Test  Results by Job Title (N = 1,100

**	****	****Post-Test  Results by Job Title (N = 1,100**

## The “S” Question:detection is job #1

- Why ask it?
- How to ask it?
- How not to ask it.
- When to ask it?
- 				Samples

## S QuestionsNot sure? Ask!

***SAMPLES***
***Have you had thoughts of killing yourself?***
***Are you considering suicide?***
***Are you contemplating ending your life?***
***Have you had any personal thoughts of death or suicide?***

## A Good S Question	

- - Have you been unhappy lately?
-  Response,  “Yes.”
- - Have you been very unhappy lately?
- 	Response, “Yes.”
- -Have you been so unhappy that you’ve been considering suicide?

## More S Questions

- Do you wish you could go to sleep and never wake up?
- Are you planning to kill yourself?
- Have you been thinking about suicide?
- Have you had recurrent thoughts of death or suicide?
- You sound miserable, do you want to die?

## Best predictor of a 2nd attempt?

- The student...
- Just ask, “How likely is it that you will make a suicide attempt?”
- 	1 		2	3 	4 	5 	6	 7
- Never 		Maybe		Absolutely will
- Note: there are no helpful psychometrics –
- 		 D. Goldston/NIMH

## Risk Assessment Questions (derived from the QPRT ©) 

- SAMPLE PROTOCOL:
-  What’s wrong?
-  Why now?
-  With what?
-  When and where?
-  With what and when in the past?
-  Who’s involved?
-  Why not now?
**	****	**

## A Risk Management Plan

- Follow medical advise/take meds?
- Stay clean and sober?
- Remove means of suicide?
- Accept referral?
- Inform family and who else?
- Call emergency response/hospital?
- Accept responsibility for personal safety?
- 	 (non-psychotic, sober, aware of internal state, etc).

## Treatment

- What we *don’t know* is much greater than what we do know.
- 7 studies on adolescent suicidal behavior
- 3 quasi experimental
- 4 RCT (limited)
- What works?
- CBT and MEDS?  CBT for relapse prevention
- CBT + MEDS? – Current major study TASA
- @ Columbia, NYU and U of South TX

## Detect risk and:

- “If it isn’t written down, it didn’t happen.”
-   T. Gutheil, 1980
- ***
- Document assessment of risk
- Complete and carry out customary treatment plan
- Team up and chart
- ***
- Twin pillars of defense:
- Consultation and documentation

## To Enhance Student Safety...

- Gain specific, evidence-based knowledge
- Ask them all!
- Assess risk or find someone who does
- Consultation is NOT a sign of ignorance, weakness, or stupidity, it is a necessary act of caring, competence and courage
- We can no longer plead ignorance; lawsuits are up and telephones, teleconferences, and the internet have removed all our excuses

##  Contact information:

- 				 Free e-book
- 		Free risk management newsletter
- Office phone: 509-235-8823
- Institute phone: 1-888-726-7926
- Email: _[pquinnett@mindspring.com](mailto:pquinnett@mindspring.com)_
- Website: _[www.qprinstitute.com](http://www.qprinstitute.com/)_