Suicide Assessment

In a suicide assessment, you want to determine lethality & severity and predict risk of immediate harm to self.  Lacking a crystal ball or other psychic abilities, you will need to rely on your clinical skills, rapport with the client, information gathered from the client’s loved ones (with a release of information, naturally), and skillful use of a suicide assessment.  You will need to gather information related to suicide risk factors.

So what are suicide risk factors, anyway?  Risk factors are a combination of individual, relational, community, and societal factors that increase the risk of suicide. Risk factors are characteristics associated with suicide and may not be direct causes.  The single greatest predictor of a future attempt is a past attempt.  I will say again, the single greatest predictor of a future attempt is a past attempt.  So, no matter what your setting, you should be asking, “Have you ever tried to kill yourself?”  You need to be direct, and use words like kill, dead and suicide, not euphemisms, such as, “Have you ever tried to hurt yourself?”  You don’t want your questions to be misunderstood on this subject.  Anyway, suicide risk factors include the following:

• Family history of suicide
• Family history of child maltreatment
• Previous suicide attempt(s)
• History of mental disorders, particularly clinical depression
• History of alcohol and substance abuse
• Feelings of hopelessness
• Impulsive or aggressive tendencies
• Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)
• Local epidemics of suicide
• Isolation, a feeling of being cut off from other people
• Barriers to accessing mental health treatment
• Loss (relational, social, work, or financial)
• Physical illness
• Easy access to lethal methods
• Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts

These risk factors are lifted directly from the CDC at http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html.  The NASW adds to this being a white male over 65 or under age 30, having a medical condition, a recent discharge from a psychiatric hospital, and being single, separated or divorced.  If you're like me, most of your clients have most of these risk factors.  Yay for working with the vulnerable, oppressed and impoverished!

Happily, there are also some factors that seem to buffer people from suicidal ideation and attempts.  However, protective factors have not been researched as extensively as risk factors have.  Please do not assume that a person who has these protective factors is not a suicide risk.

• Effective clinical care for mental, physical, and substance abuse disorders
• Easy access to a variety of clinical interventions and support for help seeking
• Family and community support (connectedness)
• Support from ongoing medical and mental health care relationships
• Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes
• Cultural and religious beliefs that discourage suicide and support instincts for self-preservation
• Having dependent children

When assessing suicidality, you want to gather information related to client’s suicidal ideation & planning.  You will ask questions about:

• Ideation – thoughts of harming/killing oneself.  These are questions like:
• Are you thinking about killing yourself?
• How often do you have thoughts of suicide?
• Have you ever written a suicide note?
• Plan – how/when the person will kill him/herself.
• When are you going to kill yourself?
• How will you kill yourself?
• Intent – level of motivation/ability to follow through w/ a suicide plan.  These are questions like:
• Do you have [whatever the means to the plan is] at home?
• On a scale of 1 to 5, how much do you want to die?
• What will happen to your [family, friends, dog, goldfish] when you die?
• Have you made any preparations for what will happen after your death?

The more clear, specific and lethal the plan, the more you want to step in and take directive action.  So, I would worry more about a plan like, "My wife and kids are away next weekend, and I'm going to shoot myself on Saturday night after they go," than I would worry about a plan like, "Well, I have a couple Valiums, and I might take them if I don't find a job soon."  Plan A is specific, lethal, with a specific time frame.  Plan B is not likely to be lethal and with no specific time frame or preparations, you may be able to talk about alternative ways of coping, use some other wonderful social work interventions, and send the client home with a plan to follow up.

A light and happy subject for a lovely Friday night!  Please feel free to add your own thoughts or experience.  I don’t think you can ever spend too much time learning about suicide assessment and prevention, particularly when you consider that suicide is the 4^th leading cause of death for adults 18 – 65 years old.

Major Depressive Disorder (MDD)

MDD is characterized by one or more major depressive episodes & no history of manic, hypomanic or mixed episodes.  MDD can begin at any age but most often onsets in the mid-20s.  The course can be quite variable.  Some people may have isolated episodes of depression with remissions of many years; others may have clusters of episodes with brief remissions.  You can use specifiers to indicate the course of the disorder, such as the specifier “With Full Interepisode Recovery” or “Without Full Interepisode Recovery.”

The criteria:

• Presence of a single major depressive episode (see previous post)
• Episode is not better accounted for by schizoaffective disorder & is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.
• There has never been a manic, mixed or hypomanic episode unless that episode is substance or treatment induced or due to a general medical condition.

• If the full criteria are met at the current time for a major depressive episode, specify its current clinical status and/or features:
• Mild (with 5 – 6 symptoms of a major depressive episode), moderate (between mild & severe), severe with psychotic features (with most symptoms of a depressive episode and psychosis) or severe without psychotic features (with most of the symptoms & no psychosis)
• Chronic – full criteria have been met for a major depressive episode for at least the previous 2 years
• With catatonic features – with 2 of the following
• Motor immobility as evidenced by muscular rigidity or stupor
• Excessive motor activity that serves no evident purpose & is not influenced by external stimuli
• Extreme negativism (resistance to instructions with no evident motive or maintenance of a rigid posture against attempts to be moved) or mutism
• Peculiarities of voluntary movement such as posturing (assuming bizarre or inappropriate postures), stereotyped movements, prominent mannerisms or prominent grimacing
• Echolalia (repeating what you say) or echopraxia (imitating your physical movements)
• With melancholic features – defined by
• Either loss of pleasure in nearly all activities or lack of reactivity to usually pleasurable stimuli at the most severe point of the episode.
• Three or more of the following symptoms:
• Distinct quality of depressed mood
• Depression regularly worse in the morning
• Early morning awakening (at least 2 hours before usual time of awakening)
• Marked psychomotor retardation or agitation
• Significant anorexia or weight loss
• Excessive or inappropriate guilt
• With atypical features
• Mood reactivity – mood improves in response to positive events
• Two or more of the following:
• Significant weight gain/increased appetite
• Hypersomnia
• Leaden paralysis – a heavy, leaden feeling in extremities
• Long standing pattern of sensitivity to interpersonal rejection that results in significant social/occupational impairment
• Criteria are not met for melancholic or catatonic features during the same episode
• With postpartum onset – episode onsets within 4 weeks postpartum