The assessment, management, and treatment of suicidality: Toward clinically informed and balanced standards of care

Exploring Service Use Disparities among Suicidal Black Youth in a Suicide Prevention Care Coordination Intervention

OBJECTIVE

The aim of this study is to examine service utilization disparities among Black youth participating in Linking Individuals Needing Care (LINC), a 90-day research-informed suicide care coordination intervention.

METHODS

An open trial pilot was conducted to examine the effectiveness of LINC in increasing access to and engagement in mental health and non-mental health services among suicidal youth (N = 587). Other variables of interest included service use facilitators and service use barriers. Generalized linear mixed models with binomial distribution and logit link were performed to ascertain if service use facilitators and barriers were associated with service utilization and if disparities in service use and engagement existed between Black and White suicidal youth through a comparative analysis.

RESULTS

Service utilization differences were found between Black and White youth. While Black and White youth were both likely to engage in individual therapy (OR = 1.398, p < .001) and non-mental health services (OR = 1.289, p < .001), utilization rates for mental health and medication management services were lower for Black (55.1% to 60.6%) youth compared to White (66.0% to 71.0%) youth. Specifically, Black youth were significantly less likely than Whites to receive medication management (OR = .466, p = .002). Systemic barriers such long waitlists for care (OR = 1.860, p = .039) and poor relationship with providers (OR = 7.680, p = .028) increased odds of engagement in non-mental health services. Clinical disorders and engagement in suicide-related behaviors increased the likelihood of obtaining care from both medication management and non-mental health services.

CONCLUSION

Care coordination services for suicidal youth can increase access and engagement in mental health and non-mental health services. Culturally adapted models attending to cultural and social assets of Black families are needed to reduce disparities and suicide risk among Black youth.

The Frontiers of Suicide

Suicide is a serious public health problem in many countries and has always been a source of apprehension and quest to human mankind, which can be resolved with due diligence. Suicide is a hidden and silent epidemic, with many causative factors. Studying and researching on various causative factors have always been the subject of significance for the researchers. Psychiatric illnesses happen to be the primary reasons for the majority of suicide mortality cases. Not only this, there has been a consistent increase in the no. of cases of mental disorders as well as attempted and completed suicide cases. If one looks at global scenario, an approximate 70,000 people commit suicide, and further alarming is the fact that the rate of suicide attempt cases has gone up to 250% during last 18 years in conflict zones. Poisoning, hanging and self-immolation are some of the common methods to commit suicide. Physical and mental illness, disturbed emotional relationships and economic difficulties were the major reasons for suicide with the predisposed population being women, student and farmers. As per WHO's approximation, there is one suicide every minute and an attempted suicide every third second. It implies that the number of killed due to suicide is greater than that of the ones killed due to the armed conflict.

Predictors of Attitudes Towards Physician-Assisted Suicide

Psychological factors may influence an individual's acceptance of euthanasia and physician-assisted suicide (PAS). The purpose of the present investigation was to evaluate predictors of attitudes towards PAS. Data were collected from 136 college students at a private Midwestern university. In addition to demographic and family history information, respondents completed measures of attitudes towards seeking mental health services, depression, hopelessness, and PAS attitudes. Respondent age, race, and hopelessness scores emerged as the only significant predictors ( R2 = .20) in a multiple regression model used to identify potential predictors of PAS attitudes. Younger, non-minority respondents, and those endorsing more hopelessness reported more accepting attitudes towards PAS. Data from a three month follow-up assessment supported the stability of this pattern. The findings highlight the important role that mental health professionals should play in PAS decision making. Implications for the evaluation of medically ill considering PAS and their caregivers are discussed.

Suicidality assessment with PRISM-S - simple, fast, and visual: a brief nonverbal method to assess suicidality in adolescent and adult patients

BACKGROUND

The PRISM-S task was developed at the Crisis Intervention Center (KIZ) Winterthur, Switzerland, to enable an assessment of the degree of suicidality in less than 5 minutes with a simple, visual instrument.

AIMS

Comparison of validity and clinical use of the new PRISM-S task with other instruments known as "gold standards".

METHOD

Quantitative pilot study enlisting 100 inpatients admitted to the KIZ, aged 15-42 years. Patients' suicidality was assessed by the PRISM-S task during the first clinical interview and compared to data obtained by standardized suicidality instruments.

RESULTS

The patients completed the PRISM-S task in 2 to 5 minutes without difficulty. Data show significant positive correlations between the suicidality as assessed by PRISM-S and the gold standards, i.e., DSI-SS (r = 0.59, N = 65, p < .0001).

LIMITATIONS

There is no strong evidence that PRISM-S is useful for outpatients or in other settings. The experiences gained with outpatients/patients with other disorders are promising but have not been systematically evaluated. The results do not rely on a randomized design. The sample consists of persons coming to the crisis intervention center.

CONCLUSIONS

PRISM-S offers a brief, easy-to-administer, and valid method to assess patients' suicidality. The simple instruction facilitates its use in other languages and other cultures as well. The acceptance by patients and health professionals was good, with no one refusing to complete the task.

A social work contribution to suicide prevention through assertive brief psychotherapy and community linkage: use of the Manchester Short Assessment of Quality of Life (MANSA)

There is a striking absence of literature articulating and evaluating clinical social work contributions to suicide prevention, despite considerable practice in this important field. This article reports on a model of assertive brief psychotherapeutic intervention and facilitated linkage to community services utilized in a prospective cohort study of emergency department suicide attempt aftercare. A key outcome measure, the Manchester Short Assessment of Quality of Life (MANSA), was used with 65 patients to assess psychosocial domains at initial presentation, 4-weeks, 3-months, and 6-months. There were significant improvements in the domains of work, finance, leisure, social life, living situation, personal safety and health by 3 months. There were highly significant correlations between psychosocial improvements and improved depression scores.

Predicting future suicide attempts among depressed suicide ideators: a 10-year longitudinal study

Suicidal ideation and attempts are a major public health problem. Research has identified many risk factors for suicidality; however, most fail to identify which suicide ideators are at greatest risk of progressing to a suicide attempt. Thus, the present study identified predictors of future suicide attempts in a sample of psychiatric patients reporting suicidal ideation. The sample comprised 49 individuals who met full DSM-IV criteria for major depressive disorder and/or dysthymic disorder and reported suicidal ideation at baseline. Participants were followed for 10 years. Demographic, psychological, personality, and psychosocial risk factors were assessed using validated questionnaires and structured interviews. Phi coefficients and point-biserial correlations were used to identify prospective predictors of attempts, and logistic regressions were used to identify which variables predicted future attempts over and above past suicide attempts. Six significant predictors of future suicide attempts were identified - cluster A personality disorder, cluster B personality disorder, lifetime substance abuse, baseline anxiety disorder, poor maternal relationship, and poor social adjustment. Finally, exploratory logistic regressions were used to examine the unique contribution of each significant predictor controlling for the others. Comorbid cluster B personality disorder emerged as the only robust, unique predictor of future suicide attempts among depressed suicide ideators. Future research should continue to identify variables that predict transition from suicidal thoughts to suicide attempts, as such work will enhance clinical assessment of suicide risk as well as theoretical models of suicide.

Promoting positive risk management: evaluation of a risk management panel

The purpose of this study was to evaluate whether a National Health Service Trust risk management panel (RMP) service was effective in promoting positive risk management by supporting mental health clinicians/teams in their management of people with mental health problems who presented with high risk of harm to themselves or to others. Fifteen mental health workers completed a questionnaire regarding their experience of the RMP. Content analysis revealed several themes. The majority of participants found the RMP helpful because of the support provided by shared case discussion and collective responsibility for risk management offered by the RMP. Medical records of the 23 individuals referred into the RMP were also examined. Trends in diagnoses, risks and RMP recommendations were identified. This study points to the importance of the organization's role alongside the individual clinician's in positive risk management and in supporting people with mental health problems using the recovery model. Improvements in developing a RMP are suggested.

Identifying and communicating clinical risk

OBJECTIVE

To develop a simple and easy-to-complete tool to communicate identified clinical risks.

CONCLUSIONS

Literature and Internet searching did not yield a simple and easy-to-use method of identifying and communicating risks. A Risk Identification Form was developed and may be of interest to mental health services wishing to implement a similar tool to document and communicate clinical risk identified during assessment of mental health consumers.

Benefits of implementing an academic training of trainers program to promote knowledge and clarity in work with psychiatric suicidal patients

A 200-hour academic, postgraduate training-of-trainers program in suicide prevention at Karolinska Institute for key mental healthcare staff, designed to enable them to enhance their co-workers' knowledge and job clarity, was evaluated in a panel study by means of questionnaires. Psychiatric staff working regularly with suicidal patients in clinics where key persons attended the course (n = 134, intervention group) were compared with staff working in clinics without participants (n = 166, control group). Perceptions of being sufficiently trained (p < .01) improved significantly among staff working in intervention clinics. Compared with the control group, the intervention group had a better understanding of essentials (p < .05); found instructions clearer (p < .01) and experienced fewer problems with superiors' differing views (p < .05) at follow up. Assistant nurses working in intervention clinics seem to have benefited most.

Suicide-preventive activities in psychiatric care: evaluation of an educational programme in suicide prevention

To promote implementation of suicide-preventive activities, the Swedish National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP) introduced a 200-h academic, postgraduate educational programme (based on the training-of-trainers model) in suicide prevention. This programme was provided at Karolinska Institute, Stockholm, for key persons in psychiatric care. Twenty-nine key persons from 11 psychiatric intervention clinics in Stockholm County attended the first course. Preconditions for implementing suicide-preventive activities were assessed by means of semi-structured interviews with all course participants still working in the intervention clinics (n=10). In all but one of these 10 clinics, a wide range of suicide-preventive activities had been implemented as a result of the NASP course. Activities varied in scope, but the key persons seemed to have succeeded in pinpointing the key elements in suicide prevention - the need for specific knowledge about the suicidal process and for well-defined suicide-preventive routines. However, organizational factors and staff turnover were obstacles to maintaining and making the activities routine. There is a need to strengthen the course participants' formal roles as implementers and encourage the clinical management in their continuous implementation of suicide-preventive activities.

The suicidal child: assessment and management of adolescents after a suicide attempt

It has been estimated that for each completed suicide, there are 15 to 20 nonfatal suicide attempts. A prior suicide attempt can create a major elevation in the risk of subsequent attempt. A prior suicide attempt also is a strong predictor for eventual completed suicide. Consequently, management of an adolescent who attempts suicide is important. In this article, the authors examine various issues related to suicide risk in adolescents. The article focuses on key issues that should be included in a thorough assessment of adolescents who are referred for an evaluation during a suicidal crisis. The empirical literature is used as a guide for identifying risk factors that should be monitored and managed as part of a comprehensive treatment plan.

Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder

OBJECTIVE

This paper has 3 objectives. First, we review the epidemiologic evidence for the association between suicidal behaviour and suicide in individuals diagnosed with antisocial, borderline, or narcissistic personality disorder. Second, we examine whether any potentially modifiable risk factors are associated with these diagnoses, based on existing empirical evidence. Last, we discuss clinical approaches to assessing youth with antisocial, borderline, or narcissistic personality disorder presenting at risk for suicide.

METHOD

We reviewed the English-language literature for the last 12 years (from January 1, 1991, to December 31, 2002), using as search terms the names of the 3 disorders, as well as the key words suicide, suicidal behaviour, youth, and adolescents.

RESULTS

Patients with antisocial or borderline personality disorder are likely to be at increased risk for suicidal behaviour when they demonstrate such comorbid disorders as major depressive episodes or substance abuse disorders, when they experience recent negative life events, or when they have a history of childhood sexual abuse.

CONCLUSIONS

For patients with antisocial personality disorder, the risk of violence has to be judged in addition to the risk of suicide or self-harm. For patients with borderline personality disorder, interventions are determined by differentiating acute-on-chronic from chronic risk of suicidal behaviour. Finally, patients with narcissistic personality disorder can be at high risk for suicide during periods when they are not suffering from clinical depression. These episodes can seem to be unpredictable.

Mental health professionals' determinations of adolescent suicide attempts

The degree of ambiguity in the term suicide attempt was examined among 14 expert suicidologists, and 59 general mental health clinicians who either did or did not receive a standard definition of the term. The participants judged whether each of ten vignettes of actual adolescent self-harm behaviors was a suicide attempt. Low levels of agreement were found within each group, although agreement was better for the most and least serious cases. Possible explanations were examined, including how professionals weight suicidal intent and medical lethality in their suicide attempt decisions, and the use of a "fuzzy," natural language conceptualization of suicide attempts was proposed.

Life stress and the symptoms of major depression

Life stress has been found to be associated with onset of depression and with greater severity of depressive symptoms. It is unclear, though, if life stress is related to particular classes or specific symptoms in depression. The association between severe life events and depressive symptoms was tested in 59 individuals diagnosed by Research Diagnostic Criteria with endogenous primary nonpsychotic major depression. As predicted, life stress was associated principally with cognitive-affective symptoms, not somatic symptoms. There also was a consistent association across different assessment methods between severe events and suicidal ideation. Finally, associations held specifically for severe events occurring before onset, not for severe events occurring after onset. Symptom variation in major depression is related specifically to severe stressors before onset and includes primarily cognitive-affective types of symptoms. There is an especially pronounced association of prior severe stress with suicidal ideation. The implications of stress-symptom associations are addressed for enlarging understanding of symptom heterogeneity and subtype distinctions in major depression.