Category Archives: Suicide Assessment and Intervention

Suicide Risk Factors: Part II

There are many ways to think about suicide risk factors. In my last post, I focused on demographic and ethnic factors related to death by suicide. In this post, the focus is on the broad category of Mental Disorders and Psychiatric Treatment. The next post will focus on Personal and Social Factors that are linked to suicide.

As you’ll see below, the relationship between mental disorders, psychiatric treatment, and suicide is complex. The following material is adapted from our textbook, Clinical Interviewing and so you can find more information there: http://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1118270045/ref=asap_B0030LK6NM?ie=UTF8

Mental Disorders and Psychiatric Treatment

In general, psychiatric diagnosis is considered a risk factor for suicide. However, some diagnostic conditions (e.g., bipolar disorder and schizophrenia) have higher suicide rates than others (e.g., specific phobias and oppositional-defiant disorder). Several diagnostic conditions associated with heightened suicide risk are discussed in this section.

Schizophrenia

Schizophrenia is a good example of a mental disorder that has a complex association with increased suicide risk. As you may realize, many individuals diagnosed with schizophrenia are unlikely to attempt suicide or die by suicide. Some individuals with a schizophrenia diagnosis are at higher suicide risk than others.

In 2010, Hor and Taylor conducted a research review of risk factors associated with suicide among individuals with a diagnosis of schizophrenia. They initially identified 1,281 studies, eventually narrowing their focus to 51 with relevant schizophrenia-suicide data. Overall, they reported a lifetime suicide risk of about 5% (Hor & Taylor, 2010). Given that the annual risk in the general population is about 12 in 100,000 and assuming a life expectancy of 70 years the general lifetime risk is likely about 840 in 100,000 or 0.84%. This suggests that suicide risk among individuals diagnosed with schizophrenia is about 6 times greater than suicide risk within the general population.

However, there are unique predictive factors within the general population of individuals diagnosed with schizophrenia that further refine and increase suicide prediction. Hor and Taylor (2010) reported the following more specific suicide risk factors within the general population of individuals with a schizophrenia diagnosis:

  • Age (being younger)
  • Sex (being male)
  • Higher education level
  • Number of prior suicide attempts
  • Depressive symptoms
  • Active hallucinations and delusions
  • Presence of insight into one’s problems
  • Family history of suicide
  • Comorbid substance misuse (p. 81)

If you’re working with a client diagnosed with schizophrenia, the lifetime suicide prevalence for that client is predicted to be higher than in the general population. Presence of any of the preceding factors further increases that risk. This leaves a “highest risk prototype” among clients with schizophrenia as:

A young, male, with higher educational achievement, insight into his problems/diagnosis, a family history of suicide, previous attempts, active hallucinations and delusions, along with depressive symptoms and substance misuse.

Given what’s known about suicide unpredictability, it’s also important to remember that someone who fits the highest risk prototype may not be suicidal, whereas a client with no additional risk factors may be actively suicidal.

Depression

The relationship between depression and suicidal behavior is very well established (Bolton, Pagura, Enns, Grant, & Sareen, 2010; Holikatti & Grover, 2010; Schneider, 2012). Some experts believe depression is always associated with suicide (Westefeld and Furr, 1987). This close association has led to the labeling of depression as a lethal disease (Coppen, 1994).

It’s also clear that not all people with depressive symptoms are suicidal. In fact, it appears that depression by itself is much less of a suicide predictor than depression combined with another disturbing condition or conditions. For example, when depression is comorbid (occurring simultaneously) with anxiety, substance use, post-traumatic stress disorder, and borderline or dependent personality disorder, risk substantially increases. (Bolton et al., 2010). Earlier research also supports this pattern, with suicidality increasing along with additional distressing symptoms or experiences, including:

  • Severe anxiety
  • Panic attacks
  • Severe anhedonia
  • Alcohol abuse
  • Substantially decreased ability to concentrate
  • Global insomnia
  • Repeated deliberate self-harm
  • History of physical/sexual abuse
  • Employment problems
  • Relationship loss
  • Hopelessness (Fawcett, Clark, & Busch, 1993; Marangell et al., 2006; Oquendo et al., 2007)

Given this pattern it seems reasonable to conclude that when clients are experiencing greater depression severity and/or additional distressing symptoms, suicide risk increases. Van Orden and colleagues offered a similar conclusion:

. . . data indicate that depression is likely associated with the development of desire for suicide, whereas other disorders, marked by agitation or impulse control deficits, are associated with increased likelihood of acting on suicidal thoughts. (Van Orden et al., 2010, p. 577)

Bipolar Disorder

Research has repeatedly shown that individuals diagnosed with bipolar disorder at increased risk of suicide. Similar to schizophrenia and depression, there are many specific risk factors that predict increased suicidality among clients with bipolar disorder.

In a large-scale French study, eight risk factors were linked to lifetime suicide attempts (Azorin et al., 2009). These included:

1. Multiple hospitalizations
2. Depressive or mixed polarity of first episode
3. Presence of stressful life events before illness onset
4. Younger age at onset
5. No symptom-free intervals between episodes
6. Female sex
7. Greater number of previous episodes
8. Cyclothymic temperament (p. 115)

These findings are consistent with the research on unipolar depression; it appears that severity of bipolar disorder and accumulation of additional distressing experiences increase suicide risk. Another study identified (a) White race, (b) family suicide history, (c) history of cocaine abuse, and (d) history of benzodiazepine abuse were associated with increased suicide attempts (Cassidy, 2011)

Post-Traumatic Stress

In 2006, renowned psychologist Donald Meichenbaum reflected on his 35-plus years of working with suicidal clients. He wrote:

In reviewing my clinical notes from these several suicidal patients and the consultations that I have conducted over the course of my years of clinical work, the one thing that they all had in common was a history of victimization, including combat exposure (my first clinical case), sexual abuse, and surviving the Holocaust. (Meichenbaum, 2006, p. 334)

Clinical research supports Meichenbaum’s reflections. For example, in a file review of 200 outpatients, child sexual abuse was a better predictor of suicidality than depression (Read, Agar, Barker-Collo, Davies, & Moskowitz, 2001). Similarly, data from the National Comorbidity Survey (N = 5,877) showed that women who were sexually abused as children were 2 to 4 times more likely to attempt suicide, and men sexually abused as children were 4 to 11 times more likely to attempt suicide (Molnar, Berkman, & Buka, 2001). Overall, research over the past two decades points to several stress-related experiences as linked to suicide attempts and death by suicide (Wilcox & Fawcett, 2012). These include general trauma, stressful life events, and childhood abuse and neglect. Characteristics of these experiences that are most predictive of suicide are:

  • Assaultive abuse or trauma.
  • Chronicity of stress or trauma.
  • Severity of stress or trauma.
  • Earlier developmental stress or trauma. (Wilcox & Fawcett, 2012)

These particular life experiences appear related to suicidal behavior across a variety of populations—including military personnel, street youth, and female victims of sexual assault (Black, Gallaway, Bell, & Ritchie, 2011; Cox et al., 2011; Hadland et al., 2012; Snarr et al., 2010; Spokas, Wenzel, Stirman, Brown, & Beck, 2009).

Substance Abuse

Research is unequivocal in linking alcohol and drug use to increased suicide risk (Sher, 2006). Suicide risk increases even more substantially when substance abuse is associated with depression, social isolation, and other suicide risk factors.

One way that alcohol and drug use increases suicide risk is by decreasing inhibition. People act more impulsively when in chemically altered states and suicide is usually considered an impulsive act. No matter how much planning has preceded a suicide act, at the moment the pills are taken, the trigger is pulled, or the wrist is slit, some theorists believe that some form of disinhibition or dissociation has probably occurred (Shneidman, 1996). Mixing alcohol and prescription medications can further elevate suicide risk.

Several other specific mental disorders have clear links to death by suicide. These include:

  • Anorexia nervosa
  • Borderline personality disorder
  • Conduct disorder (see Van Orden et al., 2010)

Post-Hospital Discharge

For individuals admitted to hospitals because of a mental disorder, the period immediately following discharge carries increased suicide risk. This is particularly true of individuals who have additional risk factors such as previous suicide attempts, lack of social support, and chronic psychiatric disorders. Overall, suicide ideation and attempts are predictably high. In one study 3.3% completed suicide within 6 months of discharge, whereas 39.4% had self-harm behaviors or suicide attempts (Links et al., 2012). Another study reported “3% of patients categorized as being at high risk can be expected to commit suicide in the year after discharge” (Large, Sharma, Cannon, Ryan, & Nielssen, 2011, p. 619).

Selective Serotonin Reuptake Inhibitors (SSRIs)

Over the past two decades, empirical data linking SSRI medications to suicidal impulses has accumulated to the point that recent administration of SSRI medications should be considered a possible suicide risk factor (Breggin, 2010; Valenstein et al., 2012). This is true despite the fact that some research also shows that SSRI antidepressants reduce suicide rates (Kuba et al., 2011; Leon et al., 2011). Overall, it appears that in a minority of clients (2–5%) SSRI antidepressants may increase agitation in a way that contributes to increased risk for suicidal behaviors (J. Sommers-Flanagan & Campbell, 2009).

In September 2004, an expert panel of the U.S. Food and Drug Administration (FDA) voted 25–0 in support of an SSRI-suicide link. Later, the panel voted 15–8 in favor of a “black box warning” on SSRI medication labels. The warning states:

Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of Major Depressive Disorder (MDD) and other psychiatric disorders. Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber.

In 2006, the FDA extended its SSRI suicidality warning to adult patients aged 18–24 years (United States Food and Drug Administration, 2007).

There’s no doubt that debate about whether SSRI medications increase suicide risk will continue. In the meantime, prudent practice dictates that mental health providers be alert to the possibility of increased suicide risk among clients who have recently been prescribed antidepressant medications (Sommers-Flanagan & Campbell, 2009).

In the next post in this series I’ll be focusing on Personal and Social factors associated with suicide.

Suicide Assessment and Intervention for the 21st Century

This past year, Alexander Street Press has been filming and producing a number of Ted-like talks focusing on counseling and psychotherapy. These are 15 minute talks, followed by a short Q & A on the topic. Below is a transcript from a talk I gave this summer in their studio at Governor’s State University in Chicago. I’m posting this talk in honor of National Suicide Prevention Day. This talk, and another couple dozen talks, should be available later this year or early next year from Alexander Street Press: http://search.alexanderstreet.com/counseling-therapy

Here’s the transcript:

Ironically I usually feel happy when I’m asked to do a talk on suicide and then I start with great confidence. I think it’s because suicide is such an extremely important and stressful issue for mental health professionals. But once I dive into the content, I remember how difficult this topic is. During one public presentation a therapist-friend of mine walked out because, as he told me later, the content was hitting too close to home. So please, as you listen, take care of yourself and talk to friends and colleagues for support.

To be perfectly honest, I DON’T REALLY LIKE to talk about suicide, but I think it’s VERY IMPORTANT that we do so directly . . . with each other and with our clients . . . and so here we go.

Death by suicide is pretty rare. Every year, only about 1 in 10,000 Americans commit suicide.

Despite its low frequency, suicide is still a major social problem that affects nearly everyone in one way or another. Over the years you’ve probably heard of many famous people who died by suicide. Marilyn Monroe and Kurt Cobain are two prime examples.

Perhaps even more important is the problem of suicide attempts. About 10% of the human population has attempted suicide and about 20% report struggling with suicidal thoughts and impulses. In surveys of high school students about 50% report “thinking about suicide.”

To summarize what we know about suicide base rates we can say:
I. Death by suicide is infrequent
II. Suicide attempts are NOT infrequent. In fact, many people attempt suicide and then go on to lead happy and meaningful lives
III. Suicide ideation (thoughts) are common
IV. And this is what makes suicide prediction very difficult, because it occurs so infrequently, but this is also what makes suicide prevention very necessary.

In 1991, I worked with a young man who ended up killing himself. This was a tragedy and I remember feeling that gut-wrenching guilt and regret that really stays with you a long time. Afterwards, my consultation group quizzed me and declared that I had done what I could, following all the standard and customary professional suicide assessment procedures. But in my mind and in my heart, then and now, I know I could have done better.

You see back in 1991, professionals (and the public) lived by a big suicide-related myth. We generally viewed suicidal thoughts as DEVIANCE. And so, when clients talked of suicide, it was our job to take action to assess and intervene to eliminate the suicidal thoughts.

This way of thinking about suicide is unhelpful. It creates distance between the professional therapist and his or her client; it also takes power away from clients. And so it’s NOW TIME FOR US TO BUST THE BIG SUICIDE MYTH.

NO LONGER should we consider suicidal thoughts and impulses simply as SIGNS OF DEVIANCE. Instead, we should view suicidal thoughts and impulses as normal signs of human distress. THIS IS THE NEW – and the more accurate – REALITY

Let’s take a minute now to contrast traditional and contemporary or post-modern suicide assessment and intervention approaches. The old Narrative is sort of a checklist approach where we emphasize risk factors, diagnostic interviewing, and no-suicide contracts. The New Narrative is different; it involves looking for protective factors, client strengths, normalizing suicide ideation, and initiating a collaborative safety plan.

This is what I wish I’d understood back in 1991. And so I’d like to be more specific about what I would have done differently and what all mental health professionals should be doing differently.
I wish I had asked more about his protective factors. Protective factors are things like reasons for living and so I wish I’d been more courageous in sitting with him and exploring the reasons why he wanted to live. I wish I’d asked him, over and over, what would or what could help him want to live.

I wish I had asked him more directly about what would help him control his suicide impulses. I would have asked him who he wanted around to help him. I would have lingered on this and asked, who else, what if that person can’t be there, who else would be your next choice to turn to for help.

One of the big changes in the suicide intervention field is that we no longer ask clients to sign No-Suicide contracts. Instead, we work to collaboratively develop a safety plan. As a part of this different focus, I wish I had clearly and unequivocally said to him: “I WANT YOU TO LIVE.” This is different than arguing with clients about their right or need to commit suicide. We should never argue against suicide because that can activate client resistance and make the act even more likely. But the language, “I WANT YOU TO LIVE” is just a self-disclosure and is therefore unarguable. It clearly communicates the intent to help.

Overall, I should have been MORE BALANCED and asked about what my client was doing when his depressive symptoms were gone. I should have asked about what he hoped for today and tomorrow and into the future. I should have asked him more about what brought a little light into his darkness. We should have brainstormed how to bring the light in when he was feeling down.
One problem with the old No-Suicide contracts is that clients sometimes viewed them as designed more to protect the counselor than the client. Obviously this is backward and not the sort of message we want to give clients who are suicidal. And so no-suicide contracts are out . . . and collaborative safety plans are in. What this requires is for counselors to dig in deeper and explore together specifically what the client is willing to do if the suicidal impulses come.

And now, because this talk is all about balancing negative and positive and I want to give an example of two suicide interventions, I’m going to share a positive story about suicide. Maybe I shouldn’t have said that, because now you already know there’s a happy ending. Oh well. Having a happy ending story is a good thing when you’re doing a suicide presentation.

About 5pm one evening I was about to head home and got a call from an alcohol and drug prevention organization across the street from where I was working. A suicidal 16-year-old had suddenly walked into their agency and they had no professional therapists on staff. They asked me to come over and help. I went right over and sat down with the girl in their lobby. We talked a while and she said she had left the local psychiatric unit and was planning to kill herself by jumping off a bridge about a quarter mile away. I listened and then began a specific suicide intervention developed by Edwin Shneidman, well-known as the father of suicidology. I said something like, “So you want to kill yourself. That’s one option, but let’s look at some others.” She said she wasn’t interested in any other options, but I got out a sheet of paper and wrote down “Kill myself” in the left hand column and asked her for other options. She said, “I don’t have any other options.” I said, how about going back to the hospital?” She said, “No way.” I said, that’s okay, we’re just making a list. Got any ideas? She said nothing. I said, “How about some family therapy?” She said, “No way.” I said, “Okay. I’ll write it down anyway because we’re just making a list. You don’t have to do any of these things.” Over time, I came up with about eight ideas of what she might do instead of kill herself, but she hadn’t come up with any. But the purpose of the intervention I was using was to address what Shneidman calls mental constriction. Mental constriction occurs when suicidal individuals are feeling so stressed and miserable that all they can consider is continued misery or death by suicide. With this intervention, I was working on opening up her mental blinders so she could see and consider alternatives to suicide. And so despite the fact that she didn’t generate or endorse any of the alternatives, I handed her the sheet of paper and asked her to rank order her preferences. And somewhat to my surprise, she ranked “Kill myself” as number three. There were two other options she preferred over suicide. I went for that and asked how I could help her get family therapy, which was her first choice. She re-escalated and headed out the door and down the street toward the bridge. I followed and walked with her and talked on and on about how “I want you to live.” She eventually got to the corner where we would cross the street to get on the bridge and I said I was stopping there. She stopped too and I reached out and grabbed her hand. She pulled back and yelled at me for touching her. Then I tried another specific suicide intervention, called Neodissociation. I said, “I know somewhere inside there’s a part of you that wants to live a happy and healthy life. Please, I want that part of you to just reach out and take my hand and walk with me back to the office so we can get you the help you deserve. She stared at me, reached out, took my hand, and then walked back to the office where I called the police and they took her back to the hospital.

[Insert big sigh here].

About two months later, I got a card from her that read, “The only bridges in my life now are bridges to health and happiness.” Now that’s a pretty good ending, but there’s more.

About six months later I asked her therapist if he thought it would be okay for me to interview her about what she thought was most helpful to her in choosing life over suicide. He asked her and then she came to my office for a short video interview. I remember asking her what was most helpful and she said she had a great student nurse at the hospital who was “Fresh” and genuine and that had helped a lot. Then I asked her what had helped her come with me on that first night we’d met. She said, “I’m not sure.” Eager for affirmation, I asked if it was when I used the neodissociation technique and she responded, “No way. That was really stupid.” Then she spontaneously said that she thought it was the look on my face, when I stopped and said I would go no further. She said that—in that moment—I looked like I really cared.

And so that’s the suicide story I prefer to remember.

Speaking of remembering, let’s review the main points.

In summary, there are three main modifications to the traditional approach, which I sometimes call the NEW MANTRA.
• There’s NO MORE BIG MYTH and so we normalize suicidal thoughts and impulses to counter our client’s feelings of deviance; they already feel deviant enough, we don’t need to add to that.
• Collaborate with clients. . . and be sure to do so from a place of genuine caring. It’s okay to say: “I WANT YOU TO LIVE” while collaboratively developing a safety plan.
• Use strength-based questioning, focusing on hope instead of hopelessness; meaning instead of meaninglessness.
• And of course, as always, like all good professionals, consult and document.

I’d like to end with a comment on self-care. As you can see in the final photo, my two daughters are engaged in what appears to be rather bizarre human behavior. I like to think of this as the one daughter performing a helpful “Pit-Check” for the other. We all need that and we especially need that when we’re working with clients who are suicidal. We need to keep talking and asking, “How am I doing?” We need to check up and check in with our colleagues and take very good care of ourselves because although the work we’re doing is essential . . . it can also be terribly stressful to face alone.

This reminds me of what another client once said to me. He said: The mind is a terrible place to go . . . alone . . . which is why we should keep on talking—directly to each other and to our clients—about suicide and suicide prevention.

Thanks for listening.